2014/15
QUALITY
ACCOUNT
Annual Report and Accounts
1
CONTENTS
Part 1:
Statement on Quality from the Chief Executive of the NHS Foundation Trust........................... 3
Part 2:
Priorities for Improvement and Statements of Assurance from the Board relating
to the Quality of Services Provided....................................................................................... 5
Information on the use of the CQUIN Framework ................................................................ 26
Information on the registration with the Care Quality Commission....................................... 26
Information on the quality of data........................................................................................ 27
Department of Health Mandatory quality indicator set to be included in the
2014/15 Quality Accounts.................................................................................................. 28
Part 3:
Review of quality performance, involvement, and external statements.................................. 32
Statement from Commissioners, Local Healthwatch organisations
and Overview and Scrutiny Committee................................................................................ 56
Joint Health Overview and Scrutiny Committee for
Pennine Care – Response to the Quality Account 2014/15.................................................. 57
Statement from local Health and Wellbeing Boards............................................................. 58
Statement of Directors’ responsibilities............................................................................... 58
Independent Auditor’s Limited Assurance Report to the Council of Governors
of Pennine Care NHS Foundation Trust on the Annual Quality Report................................... 60
2 Annual Report and Accounts
QUALITY
ACCOUNT
Part 1: Statement on Quality from the
Chief Executive of the NHS Foundation
Trust
Quality is central to all of the Trust’s ambitions to improve
services and provide the best possible care.
This has been another challenging year with ongoing financial
pressures across the whole of the NHS and within Pennine Care.
In my first year as Chief Executive of Pennine Care we have met
these challenges and have continued to develop forward thinking
initiatives to ensure that quality is central to
our ambitions to improve services and to provide the best
possible care.
Our Quality Account for 2014/15 details quality improvement
projects initiated in and implemented throughout the year across
our mental health and community services and also
sets out some of our key priorities for quality improvement as
we move into 2015/16. The priorities for quality improvement
have been chosen from the core areas of safety, clinical
effectiveness and patient experience, reflecting emergent
themes arising from consultation with clinical and operational
staff, service users, carers, the Foundation Trust membership
and the Council of Governors.
Quality is central
to all of the
Trust’s ambitions
to improve
services
and provide the
best possible
care.
This year has seen the national launch of the Friends and Family
Test, which means we ask all who use our services “How likely
are you to recommend our service to friends and family if they
needed similar care or treatment?” We began collecting this
feedback in January 2015 and to date have received over 5200
responses, indicating that 94 per cent of those receiving services
would recommend care in our organisation to their families and
friends. Moving forward we will be able to compare this response
to other organisations as a national benchmark.
Service user and carer feedback and collaborative working is a
key part of our Trust’s strategy and this year we have continued
to engage with service users on a range of projects to ensure
work streams remain true to service users and their carers’
needs. In the coming year, we will be developing a patient
experience strategy in collaboration with service users and
carers, which will ensure that their wants, needs and must dos
are effectively acted upon.
Annual Report and Accounts
3
Engaging, listening to and acting on feedback from
our staff is also a vital part of how we ensure that
services are developed to meet the needs of our
local populations. In November of 2014, we held a
“Compassionate Care for Everyone” conference which
was attended by over 250 staff from across the whole
organisation. The conference was well represented by
the range of healthcare professionals providing care
across our mental health and community services. The
conference also saw the launch of the Trust’s nursing
strategy and has led to the formation of the Healthcare
Professionals Forums. These will allow our clinical staff
to align how the organisation adapts to changes in
healthcare and enable early recognition where services
may not be working as well as we had hoped, so we
are best placed to act quickly to resolve any issues.
I and all our staff are committed to ensure that
quality will always be at the centre of the care we
provide, and in partnership with our service users,
carers, commissioners and local communities, we
will make sure that this continues to drive all service
improvements.
To the best of my knowledge, the information in this
document is accurate.
Michael McCourt
Chief Executive
27 May 2015
4 Annual Report and Accounts
Part 2: Priorities for Improvement
and Statements of Assurance from
the Board relating to the Quality of
Services Provided
Performance in 2014/15 against
Quality Indicators identified in the
2013/14 Quality Report
We are also pleased that our Council of Governors
were again able to choose a performance indicator
to be audited by our external auditor. The Council of
Governors have chosen ‘patient safety incidents’ and
as a result, an audit of our processes relating to this
indicator will be undertaken.
The Trust is confident that a high level of quality
assurance in our 2014/15 priorities can be achieved
through internal governance structures and processes,
external auditor scrutiny and joint working with our
community and mental health commissioners.
The NHS Foundation Trust identified the following
quality priorities for 2014/15 which were identified in
last year’s Quality Report.
Priority 1: Quality Thermometer – Patient Safety
Priority 2: Self Management – Patient Experience
Priority 3: Skills Mix – Clinical Effectiveness
The NHS Foundation Trust’s performance against each
of these indicators in 2014/15 is indicated below.
Further details about our performance in each of these
indicators and a selection of others, is available in
part three of this report.
The priorities as listed above were chosen to
represent quality indicators across both mental
health and community services.
Priority 1 (quality thermometer) and Priority 3
(skills mix) are new priorities for this year and as
such no comparative data is available. Priority 2
(self-management) builds on elements contained
within previous years’ quality accounts. There is no
comparative data as this examines different aspects of
the original projects.
Annual Report and Accounts
5
Performance in 2014/15:
The central component of the quality thermometer is
to provide services with an at-a-glance view of quality
for their service at a team level. The model is based
on service leads having identified and agreed three
indicators for each quality domain (safe care, effective
care and experience of care), which are then used to
generate an overall score for quality.
Priority 1: Quality Thermometer
The NHS Foundation Trust has extensive service line
reports across both mental health and community
services, each of which contain multiple performance
indicators under a range of headings, such as human
resources (HR) and finance. The reports whilst
comprehensive and detailed were not specifically
designed to allow frontline clinicians to directly
consider quality of care.
The quality thermometer gives an overall score for
the quality of service for the team or ward. The score
is calculated based on performance against each
indicator in each of the three quality domains and
allows individual teams to track quality indicators.
The NHS Foundation Trust’s quality group
commissioned a piece of work to develop a tool that
would promote consideration, interpretation and
appropriate action planning in relation to quality:
patient safety, patient experience, clinical effectiveness.
An example of a ward-based quality thermometer is
outlined below:
T240 - Quality Thermometer
Total Admissions: 31
Total Discharges: 30
Bed Capacity: 21
Quality Indicators
Domain
Indicator
Safety
Overall incidents on ward
Safety
Safety
Actual
Score
(Month) (Month)
Target
Monthly Actual Score
Trend
(YTD (YTD)
0.00
10
0.50
0.50
5
Aggressive incidents
(grade 3+)
0%
10
3%
1%
8
Medication errors
0%
10
2%
1%
6
Effectiveness Patients who abscond
(All AWOL)
0%
10
6%
3%
7
Effectiveness Patients who repeatedly
abscond (Repeat AWOL)
0%
10
9%
28%
1
Effectiveness Average trimmed length
of stay
23
5
28
31
5
1
5
1
1
5
13%
4
10%
10%
5
0%
10
9%
8%
5
Experience
Friends and Family Test
Experience
Total out of area admissions
Experience
28 day readmissions
6 Annual Report and Accounts
Quality Domains
Safety
Effectiveness
25
Experience
30
Safety
30
Effectiveness
10
13
Experience
19
0
19
20
15
0
30
10
Quality Thermometer
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Month
82%
20
30
YTD
Month
Safe Staffing
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Day
98.21%
Night
115.48%
192.86%
109.52%
52%
YTD
The quality thermometer presented above was
developed in collaboration with service leads following
multiple alterations and changes in design. The
measures, whilst not always directly indicative of the
quality domain, can be used as proxy measures to
indicate potential impacts on quality. For example,
overall incidents may be relatively high, whereas
harm or consequence may be low. A high number
may indicate high frequency of events but may have
resulted in no harm.
As the thermometers have been developed we have
also incorporated other areas into the reports to
provide further information and context. We have now
included number of admissions in month (to represent
comparative actuity) and working into the safer staffing
workstream, the ward fill rates. This allows service
managers to compare against other areas but with
added context, thus improving the overall usefullness
and visibility of the tool.
This year’s report focused on our targets to design the
quality thermometer and introducing the concept of
the thermometer at a service level. During 2015/16 the
focus will be on refining the measures and promoting
the use of the thermometer in team meetings and
comparing against other services.
Annual Report and Accounts
7
Quality thermometer roll out programme
Service
Number of
services
Target Roll Out Date
Mental Health – Inpatient Wards
10
Sept – 14
Yes
Mental Health – Older Peoples
36
Apr – 15
On Target
104
Apr – 15
On Target
Community Services – Oldham
18
Apr – 15
On Target
Community Services – Bury
34
Apr – 15
On Target
Community Services – HMR
38
Apr – 15
On Target
Mental Health – Community
The roll out for the remaining services within the Trust
is currently on target and the remaining dashboards
are currently being constructed by the information
department.
There are several sources of data that are used to
create the quality thermometer data, most notably
inpatient data (obtained from iPM) and incident data
(obtained from the safeguarding system). These are
static targets, known as ‘average target’, set against
each indicator. Actual data from the systems is then
used to assess whether or not the indicator is being
met.
The development of the thermometer has proven to be
a complex process of linking in operational and clinical
priorities against existing performance measures.
Similarly, the development of a ‘scoring’ system has
also been complicated and it was recognised that in
the early versions the score did not necessarily relate
to areas services had control over e.g. admissions
from outside of home ward catchment area. As we
continue to develop and introduce the thermometers
to other areas we again expect this to be an iterative
process.
Another key aspect of the approach is to promote the
use of the thermometers as a quality gauge and not a
performance management tool.
8 Annual Report and Accounts
Achieved
Priority 2: Self-management
As a Trust our vision is ‘to deliver the best possible
care to patients, people and families in our local
communities by working effectively with partners, to
help people to live well’. This quality priority outlines our
approach in supporting this vision through developing
self-management options. There are a number of
important considerations in the planning and delivery
of care with our patients that reinforce the importance
of developing a self-management ethos, these include:
• Around 15 million people in England have one or
more long-term conditions. The number of people
with multiple long-term conditions is predicted to
rise by a third over the next ten years
• People with long-term conditions are the most
frequent users of healthcare services, accounting
for 50 per cent of all GP appointments and 70 per
cent of all inpatient bed days
• Treatment and care of those with long term
conditions accounts for 70 per cent of the primary
and acute care budget in England
• Around 70 – 80 per cent of people with long term
conditions can be supported to manage their own
condition (Department of Health 2005)
Self-management has been identified as a key
organisational priority and enabler, which contributes
to achievement of the ambitions set out in the Trust
Service Development Strategy. Throughout 2014/2015
we have addressed self-management through three
key workstreams.
My Health My Community/
Self-Management Toolkit
supporting education and self-care for children with
asthma.
An over-arching Living Well Strategy Group has been
established to deliver shared leadership between the
development and delivery of My Health My Community
and the Self-Management Toolkit.
The My Health My Community web site is in
development, with a number of animations and videos
being created to support self-management. The
first prospectus for face-to-face courses has been
launched and courses have been delivered in Bury
and the Rochdale borough. Further courses have been
booked by the third sector.
Sugar3
With regard to applications,
was created and
launched, supporting self-management for children
and young people with Type 1 Diabetes. Development
of an asthma app has also commenced, aimed at
Bury community services are embarking on a crossborough initiative to enable teams to self-assess their
service delivery model against best practice in selfmanagement support, as well as enabling patient
feedback about how well supported patients have
felt in consultations with staff. Community teams in
the Rochdale borough have developed a number of
self-management support champions. A temperature
check has been conducted to measure shift in selfmanagement support practice across the organisation
in order to action plan for 2015-16.
Overarching outcome measures and anticipated
areas of impact have been identified as part of the
Living Well project initiation document which will be
monitored and tracked through the strategy group. For
example, outcomes from the wound care courses will
be captured as in the figure below.
Wound Care
100%
100%
100%
100%
100%
90%
80%
70%
67%
67%
60%
Excellent
50%
Good
40%
30%
Average
33%
33%
20%
Poor
10%
None
PRE
Your overall ability to
manage the care needs
you currently deal with
Your confidence in
undertaking the elements
within this topic
Your knowledge and
understanding of the
course topic
Your overall ability to
manage the care needs
you currently deal with
Your confidence in
undertaking the elements
within this topic
Your knowledge and
understanding of
the course topic
0%
POST
Annual Report and Accounts
9
All online content for My Health My Community will
have in-built analytics. Wider outcomes will be tracked
through online questionnaires and performance data,
for example better use of community resources and
carers feeling more confident to manage the needs of
those they care for.
Whilst the launch of the face-to-face courses has
been successful, there could be improvements in the
process of advertising and encouraging attendance.
The use of volunteers has proven to be very successful
in increasing awareness of the project in the Heywood
area and it is important to develop this further in other
areas.
Offering teams the toolkit and delivering workshops
and awareness-raising has had some impact; however
it is felt that further activities are needed to drive a more
robust culture of self-management support throughout
the organisation. Teams will conduct a self-assessment
of the services’ culture, which will be linked to patient
reported feedback. This approach is intended to
highlight areas of need and assist teams to engage in
the self-management toolkit for improvement actions.
Reporting mechanisms for the two elements of the
living well work stream will be through the Living Well
Strategy Group, through to the Service Development
and Transformation Committee.
Technology
Flo Simple Telehealth was piloted in a number of
pathways including the Healthy Minds Service (stress
and anxiety) and community nursing, wound care
management. This technology supports patients to
more confidently self-manage through text messaging.
Further rollout in 2015/16 will include eye patching and
Glaucoma.
The Trust has experienced early success with Flo, for
example as part of group therapy for stress and anxiety
management, service users using Flo experienced a
22 per cent improvement in clinical outcomes, and the
service saw non-attendance reduce by 37 per cent
when compared to the standard pathway.
Further work will be undertaken, reporting to the
Technology Enabled Services Steering Group, to
increase uptake.
10 Annual Report and Accounts
Strategy
A patient experience strategy and delivery plan is being
developed with a named organisational executive
sponsor and operational lead. Three staff and service
user engagement conferences were delivered, acting
as a platform to highlight areas of good practice and
also to understand how we can do things differently to
enhance the experience of patients accessing care.
The development of a patient experience partnership
meeting will continue in to 2015/16 with extensive work
already being carried out to ensure representation
from Healthwatch, CCG colleagues, Governors
and the Local Authority amongst others. It will also
ensure robust mechanisms are in place to monitor
all elements of a patient’s experience. The patient
experience partnership meeting will enhance work
streams that are aligned to the partnership meeting.
It will work to ensure that service users and carers
are involved and engaged in their care. Service users
and carer experience is captured, understood and
responded to and service user and carer experience
influences the design and delivery of improvements
and initiatives. The patient experience partnership will
oversee the ongoing review of the patient experience
strategy. Regular updates will also be provided to the
Trust’s Quality Group and where appropriate the Trust
Board.
An annual service user conference is high on the
events calendar to ensure the patient experience
strategy and associated work streams remain true to
service users and their carers’ needs, wants and must
dos. Ensuring maximum attendance at the annual
service user conference will ensure that service user’s
views are reflected in the development of the patient
experience strategy.
Development of the patient experience strategy, and
delivery of the priorities identified will be reported to the
Quality Group. Linkage between the two elements of
this patient experience priority will be achieved through
a number of staff who are part of both elements of
development.
Priority 3: Ward Skill Mix
National concerns regarding staffing levels and
the skills of staff were highlighted through the
series of enquiries concerning the failings of care
at Mid Staffordshire Hospital. In October 2013 the
Government published its response, which included a
number of requirements for the future monitoring and
measurement of staffing levels in all care settings.
In order to address these concerns, we have
progressed key areas across all of our inpatient wards
namely:
• Declaration of staffing numbers displayed per shift
• Reporting staffing numbers per shift via Unify
The safer staffing project was established to ensure
that reporting on safer staffing levels complied with the
National Quality Board’s standards. In the first instance
this was to ensure all wards had a clear display board
at their entrance that displayed the planned staff for
that shift and the actual staff available. If there was a
variance an explanation was given.
The second standard was to ensure all wards reported
their staffing levels through the Unify national database
and are published monthly, nationally. The Board also
requires the staffing levels to be taken each month and
a clear plan agreed if areas are operating with lower
than expected staffing levels.
The following table indicates compliance to these
standards:
• Planned to actual staffing number reported
• Skill mix review
Speciality area and
ward name
Staffing numbers
displayed per shift
Compliance
Reporting staffing
numbers per shift
via Unify
Compliance
Adult Acute Wards
(10 wards)
Yes
100%
Yes
100%
Older peoples
(9 wards)
Yes
100%
Yes
100%
CAMHS
(2 wards)
Yes
100%
Yes
100%
Specialist Services
(11 wards)
Yes
100%
Yes
100%
Intermediate Care
(3 wards)
Yes
100%
Yes
100%
Annual Report and Accounts
11
Skill Mix
We are also required to report required staffing establishment (qualified and unqualified) against actual
staffing on each ward during day and night shifts.
The table below demonstrates our performance against each ward area:
September 2015 – March 2015
Day
Area
Ward
DAY – % Fill
DAY – % Fill
Rate –
Rate –
Registered Unregistered
Night
NIGHT – %
NIGHT – %
Fill Rate –
Rate –
Registered Unregistered
Bury Adult
Mental Health
Bury – North Ward
98.00%
113.36%
113.81%
106.90%
Bury – South Ward
96.93%
108.49%
99.35%
107.81%
Oldham Adult
Mental Health
Oldham – Northside
96.58%
113.99%
101.33%
131.48%
Oldham – Southside
105.66%
96.38%
92.66%
108.81%
Rochdale Adult
Mental Health
Rochdale – Hollingworth
92.22%
111.44%
108.97%
124.57%
Rochdale – Moorside
98.11%
101.81%
94.61%
104.72%
Stockport Adult
Mental Health
Stockport – Norbury
126.30%
101.26%
116.98%
118.40%
Stockport – Arden
113.68%
114.62%
102.36%
126.42%
Tameside Adult
Mental Health
Tameside – Saxon Suite
94.81%
106.76%
99.53%
105.03%
Tameside – Taylor Ward
90.21%
114.47%
110.80%
115.23%
Bury – Hope Unit
93.58%
116.72%
100.94%
121.93%
Bury – Horizon Unit
77.39%
120.90%
100.47%
139.82%
Prospect – Engagement
& Assessment
109.20%
95.60%
101.42%
114.86%
Prospect – Recovery
and Inclusion
112.50%
88.21%
100.00%
101.18%
Prospect – Social
Inclusion
107.08%
88.99%
100.00%
109.43%
Rochdale –
Stansfield Place
112.50%
90.33%
100.47%
99.53%
Stockport – Bevan Place
97.41%
105.58%
101.42%
119.67%
Stockport – Heathfield
87.74%
116.27%
102.36%
97.17%
CAMHS – Bury
RHSD
12 Annual Report and Accounts
RHSD (cont)
Stockport – PICU – The
Cobden Unit
113.29%
114.98%
95.75%
155.90%
Tameside – Beckett
Place
89.94%
103.07%
100.00%
102.12%
Tameside – Hurst
Place*
93.39%
96.68%
100.66%
100.33%
Tameside – Rhodes
Place
89.03%
93.35%
100.00%
101.42%
Tameside – Tatton Ward
86.48%
103.54%
101.42%
99.76%
Bury Older
People
Bury – Ramsbottom
Ward
105.47%
164.87%
103.08%
166.92%
Oldham Older
People
Oldham – Cedar
102.36%
151.18%
101.89%
274.06%
Oldham – Rowan
84.08%
211.64%
104.25%
255.19%
Rochdale Older
People
Rochdale – Beech
101.06%
203.91%
102.36%
196.93%
Stockport Older
People
Stockport – Davenport
80.78%
125.00%
106.60%
123.35%
Stockport – Rosewood
120.05%
96.43%
100.47%
100.24%
90.25%
98.76%
103.77%
97.96%
100.41%
111.68%
101.10%
105.49%
Tameside – Summers
78.18%
157.43%
99.53%
114.39%
Bealeys
99.24%
139.09%
98.22%
104.57%
100.00%
100.14%
99.45%
101.91%
Stockport – Saffron
Tameside Older
People
Intermediate
Care
Tameside – Hague Ward
Butler Green –
Green Ward
Annual Report and Accounts
13
Safer Staffing Clinical Visits
Skill Mix Modelling
Wards with an accumulative percentage lower than
80 in any of the categories (registered and care
staff, day and night shifts) receive a Safer Staffing
Clinical Visit where assurance is sought that safety,
effectiveness, caring, responsiveness and leadership
has been maintained throughout the period of lower
staffing. The Trust has created the 80 per cent criteria
for clinical visits as there is no national criteria. The
visits are undertaken by senior nursing staff from
the Service Improvement Team and reflect the new
Care Quality Commission (CQC) inspection model
of a semi-structured deep dive exploration. Urgent
issues are addressed with ward and service managers
immediately. For less urgent issues, a meeting of key
people is arranged as soon as possible after the visit to
devise an action plan for recovery. To date the following
wards have received Safer Staffing Clinical Visits:
We have completed the first stage of dependency/
acuity modelling across all wards based on data in
relation to:
• Rosewood Ward
• Hague Ward
• Hollingworth Ward
• Rhodes Place
• Saffron Ward
• Summers Ward
• Davenport Ward
• Horizon Unit
• Rowan Ward
• Hurst Place
(10 wards from 35 have been visited)
Areas in relation to staffing were addressed (where
relevant) however, no areas of concern in relation to
quality were found as a result of these visits. Updates
are presented to the commissioner and provider quality
group to provide assurance.
14 Annual Report and Accounts
• Dependency 1 (snap shot of overall ward activity)
• Dependency 2 (more in depth analysis at patient
level)
• Professional judgement
• Sickness absence
• Training
• Establishment and banding
The second stage will be carried out in summer 2015,
with the goal of the safer staffing forum being to ensure
ongoing compliance with the NQB standards and to be
prepared for the launch of the inpatient mental health
guidelines released by NICE in Oct 2015.
Annual Report and Accounts
15
Our priorities for Quality
Improvement for 2015/16
culture, reducing harm associated with falls, pressure
ulcers, infections, venous thromboembolism, sepsis
and others.
The Trust has undertaken wide ranging consultation to
determine its quality priorities for the year, which have
been discussed and put forward by the Trust’s Quality
Group with Board agreement.
Pennine Care is supporting NHS England’s national
sign up to safety campaign and the goal to reduce
avoidable harm by 50 per cent and save 6,000 lives
nationally. Through participation in sign up to safety,
the Trust commits its Board and staff to placing safety
at the heart of the quality strategy, with setting goals on
patient safety issues.
Consultation on our priorities has included discussions
with the Board, clinicians, operational managers,
Council of Governors, service users and carers, and
our wider staff from both mental health and community
services. In addition, the views of the wider public have
been considered through a number of consultation and
engagement events where an overview of the quality
account has been presented including; the Trust’s
Annual General Meeting (AGM), Patient Advice Liaison
Service (PALS) service user and carer consultation
event and in liaison with commissioners. The three
priorities as set out below cover both mental health
and community services and have been set out to
align with agreed CQUIN indicators and Trust quality
priorities. As per previous years, the quality priorities
have been chosen to reflect areas addressing patient
safety, clinical effectiveness and patient experience.
The Trust has developed a safety improvement plan,
which sets out the organisation’s plans for the next
three years in relation to quality and safety. The plan
describes what we want to achieve and when we want
to achieve it, by bringing together our current work on
quality and safety and explains to staff and patients
what we intend to do. It also explains how, as an
organisation, we will be coordinating all of the different
external initiatives, ensuring that they add value to
our work and are not seen as an ‘add on’ or isolated
project or act as a distraction from what we are already
doing. The plan will be a key document to discuss at
all levels of the organisation. The areas the Trust will be
focusing on have been identified as:
Priority 1: Sign up for Safety – Patient Safety
• falls prevention and reducing avoidable harm,
Priority 2: Suicide Prevention – Patient Experience
• safe discharge, transfer and leave from inpatient
facilities,
Priority 3: Admission Avoidance – Clinical Effectiveness
Priority 1: Sign Up for Safety
Current Performance
In the last ten years the NHS in England has developed
an understanding of the nature and scale of the
problem in patient safety and the interventions that,
when effectively implemented, can help to make care
significantly safer.
The National Reporting and Learning System (NRLS),
an alert system which informs the NHS about areas
of concern, tells us about the types of incidents
reported across the country and has developed
interventions in relation to medication safety, improving
communication, understanding and measuring a safety
16 Annual Report and Accounts
• reducing hospital and community acquired
avoidable pressure ulcers and
• reducing omitted and delayed medications.
The senior clinical lead will ensure that the identified
sub-committee responsible for the patient safety
domain continues to monitor the delivery of the action
plan on a monthly to two bi-monthly basis, and report
quarterly progress updates to the project group. The
sub-committees will bring together and coordinate all
aspects of the safety improvement plan through the
active involvement of staff, patients, and health care
partners.
For the purpose of the Quality Account the focus will
be on falls prevention and reducing avoidable harm,
aiming to reduce avoidable significant harm caused by
patient falls by 20 per cent. More specifically, reduction
of 20 per cent in avoidable significant harm from falls
(incident grades 4 and 5) within older people’s mental
health inpatient and intermediate care facilities by 2018
from the 2013 baseline data.
How We Will Track Performance
Falls Safety Improvement plan
Patient falls are one of the most common patient
safety incidents reported within the Trust and whilst the
majority of falls result in no harm or minor injury, falls
can have a devastating impact on the patient, their
relatives and carers, and for the staff caring for the
patient.
In addition to physical injury a fall can result in:
• Psychological problems including fear of falling and
loss of confidence with movement,
• Reduced level of activity,
• Pain,
• Loss of mobility,
• Disability,
• Depression,
• Increased dependency,
• Prolonged stay in hospital,
• The need for long term residential or nursing care.
Over the last twelve months the Trust has collated
data on the number of falls and occupied bed days
and has been able to identify a significant reduction
in the number of falls in the last 12 months within our
inpatient and intermediate care facilities. The inpatient
falls group will continue its work to focus on reducing
the number of falls resulting in significant avoidable
patient harm and to promote the reduction of falls
resulting in avoidable harm.
in an attempt to prevent a reoccurrence where harm
could have been avoided. For 2013-2014 the Trust had
29 inpatient falls that resulted in significant avoidable
harm and the Trust intends to reduce this number by at
least 20 per cent.
Representative leads from our older people’s mental
health inpatient wards and intermediate care facilities,
will attend the inpatient falls group to ensure that
the actions are communicated and embedded
into practice from the action plan. Leadership and
engagement of staff in the changes to improve
practice will be key in the action plan’s success and
change agents will be identified within the priority areas
to ensure changes are implemented within their area
of work.
The inpatient falls group has produced a
comprehensive falls risk assessment document that is
being utilised in our priority areas and gives guidelines
to staff on the risks associated with falls. In addition,
the group has developed staff guidelines and a
handbook on falls prevention and a comprehensive
training package is to be rolled out to those staff
working in older people’s mental health inpatients and
intermediate care facilities.
In order to establish a further baseline on quality
an inpatient peer review audit will be completed to
establish specific areas for improvement. This audit will
be repeated towards the end of the three year plan to
provide a comparison report.
Areas for Improvement
A wealth of work has been undertaken to support the
development of an open reporting culture, in relation
to falls occurring in the inpatient units. Greater benefits
will come from viewing falls prevention as an integral
part of care on a unit. The training and awareness
sessions will allow teams to be falls aware. The training
needs to be delivered in a variety of different modes –
e-learning, face-to-face and sharing of best practice.
The Trust inpatient falls prevention group receives all
serious untoward incidents relating to falls to identify
lessons learned and themes on how to improve this
patient safety domain across all our inpatient facilities.
The group is able to collate information that informs
specific areas where improvements need to be made
Annual Report and Accounts
17
Actions Planned to Improve Performance
In relation to falls prevention, the Trust has identified
the key areas to focus on in order to improve
performance. We identified that the areas which could
make the most difference were in relation to developing
strategies against the headings of:
• Safe patient care
• Leadership
• Training and education
Our goal is to achieve a reduction of 20 per cent in
avoidable significant harm from falls (incident grades
4 and 5) within older people’s mental health inpatient
and intermediate care facilities by 2018.
How We Will Report this Priority
The project group will meet monthly and provide
assurance to the Trust’s Quality Group on the overall
progress. This will inform and provide assurance to
the Trust’s Quality Governance Assurance Committee
which has delegated authority from the Trust Board.
Priority 2: Suicide Prevention
Current Performance and Rationale for
Prioritising
The national confidential inquiry into suicide and
homicide (2014) found that in adult mental health
services, suicide is more common in those patients
receiving care under crisis intervention/home treatment
teams than those who have received inpatient care.
Recent research into suicide prevention models
suggest that contact should be made with patients
following discharge from services.
Research completed in relation to suicide rates and
trends in young people (U25) in England identified that
in 10 per cent of all suicides during the period 2002 –
2012, the service user was aged under 20 and 43 per
cent were under 18 years old. Service user suicides
in under 25s decreased until 2007 but fluctuated
thereafter with no overall trend, the peak number
was in 2010. The diagnostic profile in this group
differed from the adult group, whereby more patients
had a diagnosis of Schizophrenia or personality
18 Annual Report and Accounts
disorder. Similarly, a history of self harm, alcohol
misuse and drug misuse were more common, as was
unemployment. 11 per cent of those who committed
suicide in this group had a history of local authority
care.
In Pennine Care, whilst systems are in place for 7-day
follow up from inpatient care, those patients who have
accessed RAID or access and crisis teams do not
routinely receive any follow up to check on progress.
Additionally, a significant number of suicides are of
people not known to secondary healthcare or social
services.
The Trust’s suicide and self harm prevention group
(SSHPG) reviewed the data from national research
into suicide alongside data gathered from the Trust’s
audit on suicide and self harm to help understand the
trends and where services can improve preventative
approaches within current design. The involvement
and joint working of two external agencies, Samaritans
and Papyrus was considered, both are established and
respected organisations with a significant background
and expertise in supporting individuals experiencing
suicidal ideation. The SSHPG agreed as part of the
Trust’s Suicide Prevention Workplan to focus upon
post-discharge follow up of adults via Samaritans and
to promote HopeLine UK for young people alongside
other partnership opportunities with CAMHS and
Papyrus.
HopeLine UK is a text, email and telephone confidential
service that is delivered by Papyrus. The service can
be accessed by young people (U25) or anyone who is
concerned about a young person.
How We Will Track Improvement
In relation to Papyrus a project plan will be
implemented by CAMHS which will be monitored and
reviewed via the Papyrus steering group. Progress
reports will be fed into the Trust’s Quality Group and
the CAMHS quality and governance meeting.
In relation to working with the Samaritans, there will be
a number of follow up meetings planned to review the
number of referrals, capacity issues and to consider
how the service will be monitored.
Areas for Improvement
Following the initial development of the Papyrus project
implementation plan there will be regular meetings that
will enable feedback on access to HopeLine UK by
young people or those with concerns about a young
person. The plan will include promotion of the service,
community development projects and awareness
raising. The Samaritans has agreed with Pennine
Care to provide a follow up telephone call to service
users 18 years and over who are recently discharged
from access and crisis or RAID Services. It is believed
this would provide an open line of engagement and
communication, external to the Trust, should the
person wish to access support in the future.
Pennine Care will also be considering additional
support for those persons under 18 from other external
services.
Actions Planned to Improve Performance
The Papyrus project implementation plan will highlight
areas of best practice and increased participation with
partner organisations, as well as areas that require
further inreach and awareness raising.
As the project progresses, any areas detailed for
improvement will become integral to the project plan.
How We Will Report This Priority
Progress will be monitored via the Papyrus
implementation group, the Trusts SSHPG and the
quality group.
A project plan will be implemented by adult mental
health services, which will be monitored and reviewed
via the Trust ACF. Progress reports will be fed into the
quality group and quality and governance meetings.
Priority 3: Admission Avoidance
Schemes
Current Performance and Rationale
for Prioritising
The number of emergency admissions to hospital
(or that are admissions that are not planned and
happen at short notice because of perceived clinical
need) continues to rise at a time when NHS budgets
are under significant pressure. In 2012-13, there
were 5.3 million emergency admissions to hospitals,
representing around 67 per cent of hospital bed days
in England, and costing around £12.5 billion (National
Audit office 2013).
Avoiding unnecessary emergency hospital admissions
is a major concern for the NHS, not only because of
the cost associated with these admissions but also
because of the pressure and disruption to elective
healthcare and to the individuals admitted.
There is limited evidence on what works in reducing
avoidable emergency admissions. All parts of the
health system have a role to play in managing
emergency admissions and ensuring patients are
treated in the most appropriate settings. Within
Pennine Care, the four community services boroughs
of Bury, Heywood, Middleton and Rochdale, Oldham
and Trafford work in partnership with internal and
external partners to reduce avoidable emergency
admissions and support prompt and safe discharge
planning. Pennine Cares vision is to deliver the best
possible care to patients, people and families in our
local communities by working effectively with local
partners to help people live well.
Borough business plans will describe transformation
plans and strategic direction in line with the Trust’s
vision.
Annual Report and Accounts
19
Some examples of schemes taking place in the
boroughs are described below, this is just a small
snap shot which highlights some of the approaches
being taken, there are many other work streams and
schemes in place to support the admission avoidance
agenda.
Bury: Yellow Community Care Plans (YCCP)
and Frail Elderly (Healthier Radcliffe)
Pennine Care and The North West Ambulance Service
NHS Trust (NWAS) have launched YCCP initiative
across Bury. It is being delivered in partnership with
BARDOC (Bury, Bolton and Rochdale Doctors on Call)
and The Pennine Acute Hospitals NHS Trust.
This is a Greater Manchester CQUIN (Commissioning
for Quality and Innovation) scheme; the YCCP will help
support people with a long-term condition to be treated
by community health professionals, where appropriate,
and avoid being taken to hospital unnecessarily.
In the event that the service user phones 999, or an out
of hours GP, the NWAS paramedic or GP will be made
aware that they have a YCCP in place. The YCCP will
enable them to identify if appropriate care could be
provided by community-based health professionals
and avoid being taken to hospital unnecessarily.
This scheme is working in partnership with the
Healthier Radcliffe/ Frail Elderly project in a cohesive
and integrated approach to prevent avoidable trips to
A&E.
The town of Radcliffe in Bury has been chosen as
one of six areas in Greater Manchester to test out
innovative new ways to improve access to GP services.
The aim of the project, known as ‘Healthier Radcliffe’,
is to offer more routine and urgent GP appointments
at a time and place that is convenient for patients.
By being more accessible and responsive, the aim is
not only to meet the needs of patients and keep them
well, but also to avoid unnecessary trips to A&E. By
improving access to GP services through this pilot, it is
hoped to reduce the number of people from Radcliffe
who attend A&E and Walk-in Centres for minor
20 Annual Report and Accounts
illnesses by up to 40 per cent. The pilot will see GPs,
community, social care staff along with those working
in the voluntary sector working together to provide
more co-ordinated care and support for patients. There
are also plans for improved access to consultant-led
clinics in the community; increased support for carers;
more home-based care and named key workers with
a responsibility for co-ordinating care for patients
with complex needs. More focus will be placed on
prevention and planning of care to keep patients well
for longer, prevent exacerbations of ill health where we
can and prevent avoidable trips to A&E.
HMR: Urinary Tract Infection (UTI)
Management in Care Homes
This scheme highlights the importance of improving
and extending services to meet the health and
care needs of an increasingly older population and
provide services which may have previously been
provided in hospital, within community settings. The
UTI intervention in-reach service to residential care
homes will be coordinated and managed through the
community nursing service, who will be responsible
for the education coordination and support provided
to care home staff. This will be underpinned by
champions in each integrated adult nursing team by
utilising the skills and experience of band 4 assistant
practitioners.
The scheme involves close working between members
of the community nursing service with care home
staff to identify residents who are at most at risk of
developing a UTI and offer advice and support and
education in regard to prevention and early treatment.
There is a focus on early identification of symptoms
alongside the implementation of an individual care
plan, detailing planned preventative measures to
support and safeguard the residents’ overall health
and reduce the risk of secondary care admissions and
the need to call out a GP.
The process involves education of care staff in
identification of symptoms of a UTI- how to obtain urine
specimen and how to test for underlying infection. A
management pathway has been developed supporting
decision making processes within the care home and
highlights the timely contact with the nursing service
and GP practice if antimicrobial intervention is required.
The scheme will commence with 12 pilot care homes
in one GP cluster with a roll out plan to extend and
embed this initiative into all 39 residential care
homes across the three GP Clusters within Heywood,
Middleton and Rochdale.
Oldham: Local CQUIN Scheme 2015/16:
Reduction in Unplanned Adult Admissions
This CQUIN scheme aims to support a reduction
in the number of adults with a long term condition
(LTC) having unplanned admissions to hospital by
developing an enhanced rapid response service. In
quarter one of 2015/16 targets and milestones will
be agreed in relation to an enhanced rapid response
model and how we can build on the existing model
not only to prevent admission, but to keep people at
home in the first instance. A model will be presented in
quarter one 2015/16 for agreement.
On a similar theme, paediatric deflections in Oldham
are a key target for the Better Care Fund for the alliance
partnership. Funding has been secured for additional
clinical posts for 15 months while a programme budget
approach across acute, community and primary care
is developed. This is being project managed from the
Better Care Fund and a project plan is in place.
Trafford: Community Enhanced Care (CEC)
Service
Trafford community services has worked collaboratively
with the Trafford Clinical Commissioning Group (the
commissioners) to develop a community services
solution to contribute towards the reduction in
unplanned care costs.
This resulted in the development of a nurse-led
Community Enhanced Care Service with therapy
support, whose primary function is to deflect activity
from hospital, to community settings, where clinically
safe to do so. The service comprises an urgent care
team that takes referrals via a single point of access
from GPs, A&E departments and hospital consultants.
It also has four enhanced care neighbourhood based
teams working with GPs and managing patients
with complex long term conditions and preventing
readmissions to hospital. The service works closely
with social care colleagues in relation to obtaining
packages of care. In a nine month period, the service
prevented 1,543 A&E attendances and 760 hospital
admissions. This is an estimated saving of £1.3m to
the health economy. Trafford also had comparatively
lower unplanned hospital admissions when compared
to its neighbouring boroughs during the busy winter
period.
We will continue to monitor service activity levels and
will develop a tool for tracking estimated cost savings
to the health economy.
We will continue to carry out patient and staff surveys
and improve the opportunities for learning from these.
The service has identified other means of preventing
admissions and supporting early hospital discharge in
relation to patients awaiting a clinical decision. These
opportunities will be presented in a proposal to the
Trust and commissioners for consideration. We will
track improvement by targeting patients who have a
higher risk of hospital admissions, engage with their
GPs and measure success against reducing instances
of hospital readmissions.
How We Will Track Improvement
The Boroughs’ Quality Governance and Assurance
Committees (QGAC) have delegated authority from
the Board of Directors to manage the Trust’s Quality
Strategy and the associated Quality Governance
Framework. It will provide assurance to the Board
on the delivery of the strategic priorities within
the Quality Strategy and on the processes and
control mechanisms established for monitoring and
continuously improving the quality of service provision.
Regular updates and reporting will be presented to
the QGACs for assurance, will identify areas of best
practice, identify opportunities for service improvement
and highlight any areas that may require urgent
attention.
Commissioning for Quality and Innovation (CQUIN)
schemes have their own reporting mechanisms
through the Trust’s Assurance Team and Community
Services Quality Monitoring Group.
Annual Report and Accounts
21
Areas for Improvement
Areas for improvement will be identified through
evaluation and feedback mechanisms as described
and will be reflected in the borough service Business
Plans.
Actions Planned to Improve Performance
Patient feedback and stakeholder feedback will be
actively sought and obtained in a variety of formats
to inform improvement measures and future service
development and redesign.
How We Will Report This Priority
Each service area will be required to report progress
locally via their Divisional Business Unit in the spirit of
devolved autonomy. The priority will then be reported
on a quarterly basis to the Trust Quality Group. CQUIN
Schemes will be reported by the Assurance Team into
the Trust Quality Group.
Statements of Assurance from
the Board
During 2014/15 the Pennine Care NHS Foundation
Trust provided and/or sub-contracted one relevant
health services.
The Pennine Care NHS Foundation Trust has reviewed
all the data available to them on the quality of care in
one of these relevant health services.
The income generated by the relevant health services
reviewed in 2014/15 represents 100 per cent of the
total income generated from the provision of relevant
health services by the Pennine Care NHS Foundation
Trust for 2014/15.
The data is reviewed through Board’s monthly review of
the Integrated Governance Report. The data reviewed
covers the three dimensions of quality: patient safety,
clinical effectiveness and patient experience.
22 Annual Report and Accounts
Information on participation in clinical audits and national
confidential enquiries
During 2014/15 nine national clinical audits and one national confidential enquiry covered relevant health services
that Pennine Care provides.
During 2014/15, Pennine Care NHS Foundation Trust participated in 100 per cent of national clinical audits and 100
per cent of national confidential enquiries of the national clinical audits and national confidential enquiries which it
was eligible to participate in.
The national clinical audits and national confidential enquiries that Pennine Care was eligible to participate in during
2014/15 are as follows:
Title of Audit
Applicable to
Pennine Care?
Participation from
Pennine Care?
Antipsychotic prescribing in people with a learning disability
Prescribing in mental health services (POMH-UK)Topic 9c
Yes
Yes
Prescribing for people with personality disorder
Prescribing in mental health services (POMH-UK) Topic 12b
Yes
Yes
Prescribing for substance misuse: alcohol detoxification
Prescribing in mental health services (POMH-UK) Topic 14
Yes
Yes
National Audit of Memory Clinics
Yes
Yes
National Audit of Intermediate Care
Yes
Yes
Chronic Obstructive Pulmonary Disease
Yes
Yes
National Diabetes Foot Care Audit
Yes
Yes
Maternal Newborn and Infant Clinical Outcome Review
Programme
Yes
Yes (open participant
although no patients
fit inclusion criteria
during 2014/15)
Sentinel Stroke National Audit Programme
Yes
Yes
National Confidential Enquiry into Suicide and Homicide by
people with mental illness
Yes
Yes
Annual Report and Accounts
23
The national clinical audits and national confidential enquiries that Pennine Care NHS Foundation Trust participated
in, and for which data collection was completed during 2014/15, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that
audit or enquiry:
Title of Audit
Percentage of
cases submitted
Notes
POMH-UK Topic 9c:
Antipsychotic prescribing in people with a learning disability
N/A
47 cases submitted
across 3 boroughs
POMH-UK Topic 12b:
Prescribing for people with personality disorders
N/A
14 cases submitted
across 6 teams
POMH-UK Topic 14:
Prescribing in substance misuse: alcohol detoxification
N/A
19 cases submitted
across 4 teams
National Audit of Memory Clinics
100%
National Audit of Intermediate Care
N/A
5 teams across 4
boroughs participated
Chronic Obstructive Pulmonary Disease
N/A
External report not yet
completed
National Diabetes Foot Care Audit
N/A
Ongoing participation
Sentinel Stroke National Audit Programme
N/A
318 cases submitted to
date across 3 boroughs
(ongoing participation)
National Confidential Enquiry into Suicide and Homicide by
people with mental illness
N/A
Ongoing participation
5 out of 5 memory
clinics participated
The reports of three national clinical audits were reviewed by the provider in 2014/15 and Pennine Care intends to
take the following actions to improve the quality of healthcare provided:
Audits:
• POMH Topic 12b: Prescribing for people with personality disorder
• POMH Topic 14: Prescribing for substance misuse: alcohol detoxification
• National Audit of Intermediate Care
Formation of the Trust-wide Medical Audit Committee in 2014 has led to the three national reports receiving a
medical lead to summarise the findings and to form action plans which are currently being developed.
24 Annual Report and Accounts
The Trust undertakes a programme of local audit on clinical performance which is reported to the
Board of Directors.
The reports of 48 local clinical audits were reviewed by the provider in 2014/15 and Pennine Care intends to take the
following actions to improve the quality of healthcare provided (these represent a selection of key actions from 1 of
the audits):
Audit name: Process for the Risk Assessment of Therapeutic Activities
Action
Coordinator
Timescale
Task and Finish Group to be established to review
implementation practice and make recommendations
Director of
Operations
Complete
Risk Assessment Policy to be reviewed by Task and
Finish Group to reflect new recommendations. This will be
disseminated and implemented throughout all services by the
specified completion date.
Head of Patient
Safety
Complete
Awareness campaign to raise awareness of revised policy
requirements
Task and Finish
Group/Health and
Safety Team
Complete
Guidance, advice and support to be provided to service areas
on how to apply generic risk assessments, prepare/author
new risk assessments, (following launch of enhanced policy)
apply a risk score and seek appropriate authorisation of
activity risk assessments
Task and Finish
Group/Health and
Safety Team
Not yet due
Review of policy to include advice on clinical formulation and
review of Pre-Activity Service User Risk Assessment form
where clinical formulation is indicated
Head of Patient
Safety
Complete
Activity risk assessments scoring 8 or above should be
authorised by a Service Director
Identified service
areas
Complete
Audit of the revised Risk Assessment Policy to assess
implementation
Task and Finish
Group/Audit Lead
Underway – on target
Annual Report and Accounts
25
Information on participation
in clinical research
or on request from the Trust at Pennine Care NHS
Foundation Trust, 225 Old Street, Ashton-under-Lyne,
OL6 7SR.
The number of patients receiving relevant health
services provided or sub-contracted by Pennine Care
in 2014/15 that were recruited during that period to
participate in research approved by a research ethics
committee was 393. During 2014/15, Pennine Care
was involved in the conduct of 63 clinical research
studies.
In 2014/15 £5,293,997 was contingent on performance
against a range of national, Greater Manchester and
local indicators. The Trust has received the full value as
a result of its performance. Further information on the
financial performance of the Trust is available within the
Annual Accounts. The associated payment in 2013/14
was £4,941,486.
Participation in clinical research demonstrates Pennine
Care’s commitment to improving the quality of care
we offer and to making our contribution to wider
health improvement. Our clinical staff stay informed of
the latest possible treatment possibilities and active
participation in research leads to successful patient
outcomes.
Information on registration with the
Care Quality Commission
For 2014/15, Pennine Care met all clinical research
targets set by the NIHR. Results against these targets
are published on the NIHR website, which shows our
commitment to transparency and desire to improve
patient outcomes and experiences across the NHS.
Our engagement with clinical research also
demonstrates Pennine Care’s commitment to testing
and offering the latest medical treatments and
techniques.
Information on the use of the
CQUIN Framework
Pennine Care NHS Foundation Trust is required to
register with the Care Quality Commission and its
current registration status is “Registered”. Pennine
Care has no conditions on registration.
The Care Quality Commission has not taken
enforcement action against Pennine Care during
2014/15.
Pennine Care has not participated in any special
reviews or investigations by the Care Quality
Commission during the reporting period.
Pennine Care NHS Foundation Trust is fully registered
with the Care Quality Commission, without conditions.
Commissioner Quality Schedule
Use of the Care Quality
Commission’s Registration and
Intelligent Monitoring Report
A proportion of Pennine Care income in 2014/15 was
conditional upon achieving quality improvement and
innovation goals agreed between the Trust and any
person or body they entered into a contract, agreement
or arrangement with for the provision of relevant health
services, through the Commissioning for Quality and
Innovation payment framework. Further details of
the agreed goals for 2014/15 and for the following
12 month period are available online at: www.
monitornhsft.gov.uk/sites/all/modules/fckeditor/
plugins/ktbrowser/_openTKFile.php?id=3275
Pennine Care uses the QRP as part of its quality
monitoring processes. This allows the organisation to
ensure compliance with the regulations and where this
is not the case take appropriate action.
26 Annual Report and Accounts
The CQC publish a quality and risk profile (QRD) for
the Trust that is refreshed almost every month. This
indicates to the CQC and the Trust potential areas
of concern. It shows where we are achieving better,
average or worse than other similar organisations
against a range of indicators, including the patient
survey and the staff survey.
Pennine Care submitted records during 2014/15 to the
secondary uses service for inclusion in the Hospital
Episode Statistics which are included in the latest
published data. The percentage of records in the
published data:
Which included the patient’s valid NHS
number was:
• 99.9 per cent for admitted patient care;
• 99.9 per cent for outpatient care; and
• N/A for accident and emergency care.
Which included the patient’s valid General
Practitioner Registration Code was:
• 100 per cent for admitted patient care;
• 100 per cent for outpatient care; and
• N/A for accident and emergency care.
These results should not be extrapolated further
than the actual sample audited. Services which were
included within the sample include:
• APC – Forensic Psychiatry, Adult Mental Illness, Old
Age Psychiatry, Child and Adolescent (Over 18’s
only)
• OC – All mental health services (consultant-led
clinics only)
Information on the quality of data
Pennine Care will be taking the following actions to
improve data quality:
We will continue to work with our Data Quality
Governance Group that reports into the Trust’s
management structure. The group has developed a
Data Improvement Action plan to focus on outstanding
areas for improvement.
The Data Quality Governance Group led by the
Performance and Information Department have a
duty to support operational services to ensure that all
activity data is recorded timely, accurately and robustly
on Pennine’s electronic clinical/patient systems.
The Performance and Information Department work
closely with operational services to ensure they take
responsibility for the quality of data recorded on the
clinical system. They engage and encourage our
teams to improve both the level and quality of activity
information recorded and ensure the teams understand
the importance of this.
We feel the clinical record is an important tool for our
practitioners to understand the care being provided to
our service users. Having an accurate record ensures
our staff have the most accurate information in which
to work from.
Pennine Care Information Governance Assessment
Report overall score for 2014/15 was 68 per cent and
was graded Green.
Pennine Care was not subject to the Payment by
results clinical coding audit during the reporting period
by the Audit Commission.
Annual Report and Accounts
27
Department of Health Mandatory quality indicator set to be included in
the 2014/15 Quality Accounts
In addition to the indicators detailed later in this report, the following additional indicators and statements are
required to be reported in 2014/15.
2013/14
CPA 7 day follow up
95.0%
2014/15
97.4%* A
National Range
Threshold
92.5 - 100%
95%/97.4%
Pennine Care considers that this data is as described for the following reasons; to show the percentage of patients
on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care
during the reporting period.
The Trust has taken the following actions to improve this percentage, and so the quality of its services, by continuing
to monitor adherence to the above target and to take any remedial action if required.
(Figures reported as per compliance framework)
*Please note there has been a slight improvement in the reported performance (to Monitor) of CPA 7 day follow up
indicator from 97.2 per cent to 97.4 per cent. This is due to a recent data cleansing exercise.
2013/14
CRHT Gatekeeping
99%
2014/15
99.2% A
National Range
Threshold
90.7 - 100%
95%/98.3%
The Trust considers that this data is as described for the following reasons; to show the percentage of admission
to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting
period.
The Trust has taken the following actions to improve this percentage, and so the quality of its services, by continuing
to monitor adherence to the above target and to take any remedial action if required.
(Figures reported as per compliance framework)
28 Annual Report and Accounts
Mental health 28-day
emergency readmission
rates
Age Range
2013/14
2014/15
Adult Wards
18 – 65
11.5%
12.5%
N/A
10%
Older Adult Wards
Over 65
8.5%
5.6%
N/A
5%
0 – 15
0.0%
0.0%
N/A
NK
Over 16
8.5%
9.1%
N/A
NK
CAMHS Wards
National Threshold*
Range
Pennine Care considers that this data is as described for the following reasons; to show the percentage of patients
aged 0-15; and 16 or over, readmitted to a hospital which forms part of the trust, within 28 days of discharge, from a
hospital which forms part of the trust, during the reporting period.
The Trust has taken the following actions to improve this percentage, and so the quality of its services, by continuing
to monitor readmission rates to feed these back into operational services to look at systems and processes to make
improvements (e.g. RAID).
*Averages taken from NHS Benchmarking MH Inpatient Report
Internally generated reported readmission percentages
Patient Experience – Community
Mental Health
2013/14
2014/15
8.3
8*
National Range National Average
N/A**
N/A
Pennine Care considers that this data is as described for the following reasons; to show the Trust’s patient
experience of community mental health services indicator score with regard to a patient’s experience of contact with
a health or social care worker during the reporting period.
The Trust has taken the following actions to improve this score, and so the quality of its services, by continuing to
actively engage with our service users to capture patient experience through the use of satisfaction kiosks and other
means to provide direct service feedback to inform any required actions.
Note: Scores are out of a possible ten, information obtained from CQC NHS National Patient Survey 2014.
*Data is not directly comparable to the previous year due to changes within the survey.
** There is no National Range available for this indicator, however, the CQC have stated that in relation to comparable
organisations, we are ‘about the same’. Data can be found: http://www.cqc.org.uk/provider/RT2/survey/6
Annual Report and Accounts
29
Department of Health Mandatory quality indicator set to be
included in the 2014/15 Quality Accounts continued
Patient Safety Incidents
2013/14
Q1 + Q2
2013/14
Q3 + Q4
Total number of incidents ***
2,246
1,811
Rate per 1000 bed days
Number of incidents
resulting in
*National Range
Q3 + Q4
Lowest Highest
665
5,906
9.73
National
Total
107,807
21.17
17.07
58.69
N/A
Severe Harm
0 (0%)
0 (0%)
0 (0%) 36 (0.6%)
367 (0.4%)
Death
14 (0.6%)
20 (1.1%)
0 (0%) 52 (0.9%)
717 (0.8%)
14 (0.6%)
20 (1.1%)
**N/A
Total number of incidents resulting in severe
harm or death
**N/A
1.1%
Pennine Care considers that this data is as described for the following reasons; to show the number and, where
available, rate of patient safety incidents reported within the trust during the reporting period, and the number of
percentage of such patient safety incidents that resulted in severe harm or death.
The Trust has taken the following actions to improve this percentage, and so the quality of its services, by reviewing
SUI’s the Trust’s Patient Safety Improvement Group will identify learning to improve systems and the quality and
safety of patient care.
Note: * Data filtered by trusts reporting six months of activity.
** Different NHS Trusts, unable to combine to provide total
*** This is not intended to indicate performance but instead to show the National range, the number of incidents will vary influenced by the size of the NHS organisation and differences in population.
2013/14 Data reflects six monthly reporting period Quarter 1 + Quarter 2 April – September 2013 and Quarter 3 + Quarter 4
October 2013 – March 2014 (updated figures not yet available).
Full year figures (2014/15) reported internally as follows;
• Total number of incidents = 4524
• Number of incident resulting in severe harm or death = 436
Therefore outturn for 2014/15 is 9.6 per cent based on (436/4524)
Presented for auditing purposes as part of the Council of Governor selected indicator for 2014/15 .
30 Annual Report and Accounts
Annual Report and Accounts
31
Part 3: Review of Quality
performance, Involvement, and
External Statements
Working Closely with Commissioners
to Drive Quality
Throughout 2014/15 we have continued to work
closely with our mental health and community services
commissioners to ensure that providing quality care
remains the central and most important aspect of how
we develop and deliver services.
Our joint commissioner and provider quality groups
provide challenge and scrutiny as to how we provide
services and in doing so promote an ongoing culture
of openness, transparency and collaborative working.
In addition to our quality groups, we also recently
held a quality review in response to our mental health
commissioners, to provide an in depth review of work
streams in relation to patient experience, psychological
therapies and incident reporting in order to provide
assurance on our approaches and to ensure quality is
central to all we do.
Current view of the Trust’s position
and status for quality
During 2014/15 the Trust has continued to drive service
improvement schemes with a focus on quality. Part
three of this Quality Account details nine of the quality
improvement priorities chosen by the Board following
ongoing consultation with our service users and carers,
commissioners, Trust membership, and our local
communities and partner organisations.
We have also included a report on drug and alcohol
services within the nine quality indicators; Patient
Experience – BUILD aftercare.
Friends and Family Test
The National Friends and Family Test (FFT) came into
effect for both community and mental health services
from the 1 January 2015.
The FFT is a feedback tool that supports the
fundamental principle that people who use NHS
services should have the opportunity to provide
feedback on their experience and that the feedback
should be used to improve services for patients.
The FFT question asks if patients would be likely
to recommend the services they have used and
offers a range of responses. When combined with
supplementary follow-up questions, the FFT question
provides a mechanism to highlight both good and poor
patient experience.
In order to meet this national metric and ensure
compliance across Pennine Care, a number of
measures have been introduced to support teams to
implement the FFT.
A number of modes are routinely available for services
to access to capture patient feedback and the national
FFT in the forms of:
• Survey Kiosks
• Postcards
• SMS Texting
• Paper questionnaire
In response to requests from our commissioners
we are pleased to introduce a review of our quality
initiatives in 2014/15 by giving an overview of how we
are taking an organisational approach towards:
Additional work is under way to develop accessible
child friendly versions of the FFT (in line with National
guidance) to ensure the voice of the child is captured
as well as the parent.
• Friends and Family Test
The data captured will be submitted to Unify and NHS
England on a monthly basis in accordance with the
national guidance.
• Patient experience
• Lessons learned
• Safeguarding adults and children
32 Annual Report and Accounts
The following table represents the figures
(year to date):
Area
Completed
FFT Score
Mental Health
1,031
88%
Community
4,213
95%
Trust wide
5,244
94%
Patient Experience
Following the implementation of the national Friends
and Family Test in January 2015 work has been
undertaken to review the modes used to capture the
experiences of patient accessing services. These
modes have been simplified and aligned to the
national FFT. The use of an external provider will enable
the data from all sources to be blended to form more
robust mechanisms for capturing and reporting the
experiences of patients, whilst providing assurances
to the Trust Board as well as our patients that their
comments are actively listened to and acted upon.
The enhancement of the system used to capture and
record incidents, PALS and complaints will also act as
a catalyst to act upon the data received.
the information across all areas, whilst linking into
the Patient Experience Partnership Meeting. The
governance forum will act as a conduit to operational
services.
Patient experience hubs will also be introduced
within the boroughs to undertake the analysis and
triangulation of all areas of patient experience.
Lessons Learned
CQUIN theme
Pennine Care will focus on the management of ‘action
plans’ in relation to serious untoward incidents (SUIs)
as the theme for improvement in regards to the mental
health and community lessons learned once CQUIN.
Strategy
The Trust has well established and robust governance
processes for reporting and investigating incidents.
This practice is successful in identifying contributory
factors and capturing action points, however, it does
not always provide assurance that we appropriately
manage SUIs and are proactive in ensuring change to
prevent reoccurrence of the same or similar incidents.
The development of a patient experience partnership
meeting with representation from Healthwatch, CCG
colleagues, Governors and Local Authority will also
ensure robust mechanisms are in place to monitor
all elements of a patient’s experience. The patient
experience partnership meeting will enhance work
streams, which will be aligned to the partnership
meeting and works to the following elements:
The Trust has utilised the CQUIN as an opportunity to
ensure lessons learned from SUIs are communicated
organisationally and embedded into practice. This
approach taken is aimed to promote knowledge
management, organisational learning and deliver
sustained change.
• Service user and carers are involved and engaged
in their care,
To understand the processes, a systematic approach
has been taken to assess the knowledge and
understanding of staff in the services, both operational
and corporate level.
• Service user and carer experience is captured,
understood and responded to,
• Service user and carer experience influences
the design and delivery of improvements and
initiatives.
A quality governance forum is also to be established
in order to further explore patient feedback, incidents,
PALS, complaints and compliments, triangulating
Framework for Process Improvement
The process used a number of approaches:
• Brainstorming
• Focus groups
• Staff surveys
Annual Report and Accounts
33
• DRIVE – problem solving methodology
What we will do next
• PDSA Cycle
Once the systems are in place, the Trust Governance
structure will focus on sharing of good practice,
promoting lessons and testing out if services have
responded to the change needed to ensure the
incidents do not continue. Newsletters, intranet, and
learning forums will be used across the footprint.
The focus group generated great ideas for how we
consider innovative ways to promote learning.
Baseline
Focus groups were held in February and June 2014
with representation from clinical and corporate services
from across the Trust’s footprint. The data gathered
informed the development of a staff survey which
established the baseline for comparison at quarter 4 of
the CQUIN project.
Project Plan
A project plan has been developed which meets
the requirements of the CQUIN. A gantt chart
demonstrates the Trust project plan for the
implementation of CQUIN. Quarterly reports include
progress updates with supporting evidence which
reflects ‘in-year milestones’.
Pilot of the proposed action plan
The pilot of our newly developed action plan is
currently underway. The action plan allows two
additional filters. One is to identify what domain the
recommendation being made falls under Patient Safety
/ Patient Experience / Clinical Effectiveness / Process
issue.
The second filter allows the author of the action plan
to propose at what level the recommendation is to
be pitched at Trust-wide / Borough / Service / Team
/ Individual. This would then be agreed at the PSIG
meeting.
It is anticipated that the two additional filters with a
process of agreed themes, that the recommendations
will promote greater ownership within the teams
and services. The safeguard system is currently
being revised to allow greater use across services.
Monitoring the recommendations via safeguard will
allow the data to be presented in a more meaningful
way for staff, for example how many patient safety
incidents recoded for any one team. This will be easily
extracted from the system. A process of assurance
will then be embedded, via governance, so that from
team level up to the Board, we see the assurance that
recommendations are being implemented.
34 Annual Report and Accounts
Safeguarding update
As a leading healthcare provider Pennine Care
recognises its requirements to demonstrate that we
have safeguarding leadership and commitment at all
levels of our organisation and that we are fully engaged
and in support of local accountability and assurance
structures, in particular via the LSCBs, LSABs and our
commissioners. Most importantly, we strive to ensure
that a culture exists where safeguarding is ‘everybody’s
business’ and therefore Pennine Care is committed to
embedding safeguarding at the heart of its services
and to promoting the safety, welfare and wellbeing of
adults and children at all times.
The Trust currently operates in partnership with the
six local authorities. Joint work is undertaken in
relation to the development of multi-agency policy and
procedures, training and serious investigations.
There is a clear line of accountability for safeguarding
from borough and divisional Directors direct to the
Board Lead for Safeguarding.
The Executive Director of Nursing and Healthcare
Professionals in collaboration with Divisional
Directors, continues to review the form and function
of safeguarding within the organisation, in conjunction
with the implementation and implications of the 2014
Care Act.
Children’s safeguarding
Pennine Care as with all other NHS bodies, has a
statutory duty to ensure that it makes arrangements
to safeguard and promote the welfare of children and
young people and that such arrangements reflect the
needs of the children and young people to whom they
provide services.
Children and young people should all be able to grow
and develop in circumstances where they are safe and
supported, so that they can reach optimal outcomes
throughout childhood, their teenage years and into
adulthood.
Key work streams:
• Continued development and review of
safeguarding supervision models
• To complete the safeguarding audit as per Trust
audit calendar and participate in the externally
commissioned audit
• Embed and review the proposed safeguarding
structures across the Trust
• Continue to review the safeguarding training
strategy in line with the new Royal College
of Paediatric and Child Health Intercollegiate
Competencies Documents 2014
• To ensure level 2 and 3 training is delivered in
compliance with the intercollegiate document 2014
and is mindful of lessons learnt from SCRs
• To develop good practice forums with safeguarding
teams across the Trust footprint
Key achievements:
• Membership of Greater Manchester Safeguarding
Partnership Policy Group and review of multiagency policies for mental health services
• Involvement in SCRs, DHRs and learning reviews
Adult Safeguarding
Pennine Care, as with all other NHS bodies, has a
statutory duty to ensure that it makes arrangements
to safeguard and promote the welfare of adults,
protecting a person’s right to live in safety, free from
abuse and neglect.
The implementation and functioning of the LSABs vary
across the boroughs as the Care Act is implemented
but will strengthen when it becomes statutory in April
2015.
Key Work Streams:
• Partnership working with the six CCG Designated
Nurses to review a joint Assurance Framework for
safeguarding
• Set safeguarding adults within the services
strategic objectives
• Use of integrated governance systems and
processes to prevent abuse occurring and respond
effectively where harm does occur
• Work with the LSABs, patients and community
partners to create safeguards for patients
• Provide leadership to safeguard adults
• Review of the Pennine Care Adult Safeguarding
Policy, reflecting the recommendations within the
Care Act
• WRAP3 training programme implemented and
continues to be delivered to all staff
• All staff holding a paediatric caseload receive 1:1
mandatory case-led safeguarding supervision to
facilitate formative challenge and action planning
to ensure best outcomes for children. In addition,
supervision has been extended to staff nurses,
nursery nurses and allied health professionals.
• Development and implementation of the Adult
Safeguarding Practitioners within borough
safeguarding teams
• Compliance with Section 11 requirements
Key Achievements
• Development of level 3 Adult Safeguarding training
packages
• Successful recruitment to Adult Safeguarding
Practitioner roles
• Improved access to MCA and DOLS training for
community staff
Annual Report and Accounts
35
• Compliance with GM Assurance Framework for
Safeguarding Children and Vulnerable Adults
• Membership on Channel Panel Meetings within
each locality
Review of Quality Performance in
2014/15 against the three quality
domains
Below is a review of various performance quality
indicators in the year 2014/15. These indicators cover
three examples each contained within the three quality
domains of patient safety, clinical effectiveness and
patient experience. Three of these indicators fully detail
the quality priorities for 2014/15, identified in last year’s
Quality Account and detailed in part two of this report.
The following indicators have been chosen to represent
the broad overview of service quality across the
organisation; comparative data has been included to
indicate continuity and progression where available.
Self-management detailed under patient experience
builds on elements contained with previous years
Quality Accounts. There is no comparative data as
this examines different aspects of the original project.
The other quality initiatives are new for 2014/15. The
rationale for changing the reporting of priorities in
2014/15 against those presented in 2013/14 are as
follows; the remaining priorities are new initiatives
commenced in 2014/15 or extensions of key work
streams not previously reported and are presented
with the intention to show that the Trust continues to
introduce new and innovative service improvement
projects as well as building on, and improving existing
services to improve the quality of care for service users
and carers across the organisation.
These initiatives have also been introduced in
response to changes in the needs of local populations
and in response to changes in commissioning priorities
and national programmes. These reflect themes
from previous Quality Accounts in relation to safety,
effectiveness and experience.
Where available, comparative and benchmark data
has been included and unless otherwise stated the
36 Annual Report and Accounts
indicators are not governed by standard national
definitions and the source of the data is the Trust’s
local systems.
Review of Quality Performance in
2014/15 against the three quality
domains
Review of Patient Safety indicators:
Patient Safety Indicator 1: Quality
Thermometer
Description of Issue and Rationale for
Prioritising
The Trust has extensive service line reports across
both mental health and community services, each of
which contain multiple performance indicators under
a range of headings, such as human resources and
Finance. The reports whilst extremely comprehensive
and detailed were not specifically designed to allow
frontline clinicians to directly consider quality of care.
The Trust’s Quality Group commissioned a piece
of work to develop a tool which would promote
consideration, interpretation and appropriate action
planning in relation to quality: patient safety, patient
experience, clinical effectiveness.
The central component of the Quality Thermometer is
to provide services with an at-a-glance view of quality
for their service at a team level. The model is based
on service leads having identified and agreed three
indicators for each quality domain (Safe Care, Effective
Care and Experience of Care), which are then used to
generate an overall score for quality.
Aim/Goal
One of the key components of the Quality Risk
Profile was the development of a team level Quality
Thermometer, the primary aim of which is to provide
services with an at-a-glance view of quality for their
service.
The model approved was based on service leads
identifying and agreeing three indicators for each
quality domain (Safe Care, Effective care and
Experience of Care), which are then used to generate
an overall score for quality, shown in the thermometer.
The implementation of the dashboard across all
services will allow for triangulation of information, better
aligning quantitive and qualiatative data.
Service Managers; this includes colour scheme,
weighting issues and indicator choice. The information
team is currently reviewing the reporting mechanisms
in place to ensure that all services (community and
mental health) can commence on target. Meetings
continue to progress this to ensure this is finalised by
financial year-end. All services are currently on track to
go live (as outlined in part two of the report).
Current Status
Identified Areas for Improvement
A Quality Thermometer dashboard has been
created for all adult inpatient wards and is now sent
out remotely on a monthly basis. The dashboards
are currently being amended in order to capture
information relevant to each ward as specified by
In part two of the report we have reported on progress
against the introduction of the Quality Thermometer,
below is another example of an actual ward report:
T240 - Quality Thermometer
Total Admissions: 26
Total Discharges: 24
Bed Capacity: 20
Quality Indicators
Domain
Indicator
Safety
Overall incidents on Ward
Safety
Safety
Actual
Score
(Month) (Month)
Target
Monthly Actual Score
Trend
(YTD (YTD)
0.00
10
0.50
0.65
4
Aggressive incidents
(grade 3+)
0%
10
3%
2%
6
Medication Errors
0%
10
2%
2%
5
Effectiveness Patients who abscond
(All AWOL)
0%
10
6%
4%
7
Effectiveness Patients who repeatedly
abscond (Repeat AWOL)
0%
10
9%
39%
1
Effectiveness Average trimmed length
of stay
24
5
28
26
5
1
5
1
1
5
Experience
Friends and Family Test
Experience
Total Out of Area Admissions
8%
6
10%
9%
5
Experience
28 Day Readmissions
8%
5
9%
10%
5
Annual Report and Accounts
37
Quality Domains
Safety
Effectiveness
25
Experience
30
Safety
30
Effectiveness
10
13
Experience
16
0
15
20
15
0
30
10
Quality Thermometer
79%
Month
30
YTD
Month
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
20
Safe Staffing
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Day
97.32%
Night
108.33%
100.00%
104.29%
48%
YTD
The original scoring mechanism has caused some confusion amongst services leads and it has been requested
that this is amended. A change in the weighting for each indicator is being developed.
As the dashboard is used to monitor and improve quality, services were uncomfortable with a RAG rating being
applied to the scores as this seemed like services were failing in certain areas which was not the case. The
dashboard now has a neutral colour scheme which has been approved by services.
38 Annual Report and Accounts
Current Initiatives
Immediate changes have incorporated elements of the
Francis Report requirements of reporting safer staffing
figures to the dashboard. This is now reported in place
of the current commentary box.
Quality thermometer dashboards for mental health
wards have now been created and have been
distributed via automated emails for the past three
months.
The information team are continuing to engage with
services and have worked on processes that will allow
all services to choose from a selection of indicators
which will be instantly reportable month on month.
New Initiatives
The information team are working to introduce a new
scoring mechanism which will weight each indicator
separately. The Trust will investigate the possibility
of gaining external validation on the dashboard. The
dashboard will in time be embedded in to current
reporting mechanisms within the Trust.
Annual Report and Accounts
39
Patient Safety Indicator 2: Pulmonary
Rehab Pilot
Description of issue and rationale
for prioritising
Evidence indicates that people with co-morbid mental
health problems can gain large benefits from inclusion
in self-management support. (Kings Fund, Long Term
Conditions and Mental Health (2012)). “Treating a…
mental health problem by itself does not always
translate into.. lower mortality from physical illness.
More significant effects can be gained by integrating
treatment for mental health and physical health…”
(Cimpean and Drake 2011).
Aim/goal
The Pulmonary Rehabilitation Service, wished to
ensure patients were activated at the point of starting
rehabilitation. Outcomes for the patients and the
service would be improved by ensuring patients were
motivated to attend and complete the programme.
The service had supported patients with mental health
needs, who also had COPD, to attend the group
sessions previously but only small numbers of patients
were referred. The team therefore launched a pilot to
increase the referral rate into the service for patients
suffering from chronic obstructive pulmonary disease
and also a mental health problem.
Staff within the Heywood, Middleton and Rochdale
COPD pathway received a training programme
regarding supported self-management. The team
was inspired and enthusiastic following on from the
training and wished to explore the impact of modifying
their service delivery to ensure patients were activated
(motivated to engage and change behaviour) at
the point of starting rehabilitation. The team were
also determined to review the current pathway and
how patients accessed the service. Outcomes for
the patients and the service would be improved
by ensuring patients were motivated to attend and
complete the programme. The service has case
studies to demonstrate how the use of the supported
self-management approach gains behaviour change
and increased efficacy of self-management.
Occupational Therapists within the service led the
pilot and linked with mental health staff within the
organisation and also to Mind. Patients were identified
and clinical assessments carried out, risk assessments
ensured which patients were seen in either group
or domiciliary settings. Those patients with mental
health needs who had access to the pathway would
be activated due to recent mental health intervention
and hopefully be more receptive to supported selfmanagement and education, for example smoking
cessation.
One area which the service wished to explore was that
of Chronic Obstructive Pulmonary Disease (COPD)
patients with mental health needs who would benefit
in the long term from accessing the service. The
Pulmonary Rehabilitation Service provides rehabilitation
to patients with respiratory presentations; also
including a same day response to those with urgent
need for assessment due to an acute exacerbation
of COPD and A&E avoidance. The service addresses
the anxiety associated with breathlessness but also
recognises the need for expert opinion regarding the
mental health status of the patients accessing the
service as required and alerts appropriate agencies
accordingly.
The pilot integrated with mental health staff within
Pennine Care and Mind. Patients identified underwent
clinical assessment and a risk assessment ensured
safe location of intervention.
Current status
The service evaluated the pilot for activated patients
with mental health needs accessing the service and
the results were positive.
Group sessions were kept small but the outcomes for
patient experience were positive:
• “The rehab is an excellent… worthwhile course,
very helpful and staff outstanding. Very informative
and to help cope with understanding COPD, I
would recommend it to other people.”
• “I found the course has helped me mentally and
physically … been brilliant”
• “I became unwell physically and mentally. I felt ok
40 Annual Report and Accounts
in the group but I couldn’t stop the silly thoughts
in my head. I stopped going out and I needed my
depot injection. It was a really good course; I didn’t
think I could exercise! I’m doing exercise at home
now - trying to stop smoking.”
Identified Areas of Improvement
The experiences of this small pilot can be transferred
and magnified within community services and
specifically within our identified communities. There is a
need to be proactive in managing patients globally. By
joining up mental health to physical health pathways
and integrating the approach to care, the outcomes
for long-term health for those with mental health
needs with long term physical conditions can be much
improved. At present many patients with mental health
needs are not accessing pulmonary rehabilitation and
if they do, the referral may not be at the right time i.e.
when they are not activated. Other members of the
community who have long term conditions may not
be accessing all they require; by ensuring activation,
rehabilitation and behaviour change can be promoted.
Current Initiatives
There is opportunity to engage with this approach
across the management of long-term conditions;
also to ensure that hard to reach communities have
bespoke groups ongoing, as opposed to providing a
response to specific issues. Community engagement
is key to ensuring all parts of our community have the
opportunity to be engaged.
New Initiatives
The Expert Patient Programme is linked strongly
with all communities and will be the launch pad for
new initiatives regarding the recruitment of patients
with mental health needs who also have long term
conditions accessing the appropriate health and social
pathways.
Patient Safety Indicator 3: Six Months Stroke
Review
Description of Issue and Rationale for
Prioritising.
People who have experienced a stroke are at
increased risk of secondary stroke, which can often
lead to a greater loss of independence and reliance on
support services. In 2013 the Stroke Association found
that 11.1 per cent of people experienced a second
stroke in the first year following their initial stroke, rising
to 26.4 per cent within five years.
In 2006, the Department of Health highlighted the need
for people with long-term conditions, including stroke,
to continue to feel supported in understanding and
taking control of their condition, have assistance when
required in navigating the system and access to the
services they need.
The National Stroke Strategy 2007 and subsequent
national stroke guidelines have recommended that
regular reviews are a way of providing this support,
education in condition management and secondary
stroke prevention and access to resources. The
National Stroke Strategy (2007), Royal College of
Physicians National Clinical Guideline for Stroke (2012)
and stroke rehabilitation, long-term rehabilitation after
stroke (NICE 2013) state that reviews should occur
at six months then annually. In Trafford, we identified
that patients were being offered annual reviews by
the Stroke Association but that there was a gap at six
months.
Aim/goal
• To provide continuity of care and support to
patients
• To identify any unmet rehabilitation needs
• To identify any changes in condition and/or
circumstances
• To reduce risk of further stroke
• To improve communication with other primary care
and voluntary sector services
Annual Report and Accounts
41
Current Status
Current Initiatives
Using the Greater Manchester Stroke Assessment Tool
(GM-SAT), in line with Collaboration for Leadership
in Applied Health Research and Care (CLAHRC)
for Greater Manchester, the Community Neuro
Rehabilitation Team (CNRT) started carrying out
reviews of their stroke patients at six months post
hospital discharge in January 2014.
The stroke nurse is currently involved in a focus group
with CLAHRC to adapt the GM-SAT to become more
appropriate for people in 24 hour care. The GMSAT was identified as being more relevant to stroke
survivors who have continued to live within their own
home and the group are working to create a new
version of the tool which will better meet the needs of
people living 24 hour care environments.
Where appropriate, all stroke patients referred to
Trafford CNRT are offered a six month review. The
reviews are carried out by the stroke nurse on the team
at the patients’ own home and takes approximately
45 minutes. Using the structure of the GM-SAT the
review addresses stroke risk factors, medication
management, health needs, mental health, social
needs, social participation and carers’ needs.
A small survey of randomly selected patients who had
undergone the review found that people feel they are
well supported throughout their stroke recovery.
Through a review of therapy goals and health and
social needs any unmet needs or changes in condition
are identified. The stroke nurse is able to offer
specialist advice and support at the time or refer the
patient back to the appropriate CNRT therapist or other
appropriate services, including carer support services.
The stroke nurse is able to assess the patient’s risk
factors for further stroke and is able to give specialist
education and support in areas such as management
of hypertension, medications, cholesterol, smoking
cessation, exercise and diet.
Identified Areas for Improvement
We identified that communication between CNRT, GP
services and the voluntary sector could be improved.
GP’s are now provided with a copy of the review and
are immediately informed of any urgent issues. A
strong working relationship has been developed with
the Stroke Association in Trafford who regularly attend
CNRT Multi-disciplinary team meetings. This has led
to members of CNRT being invited to speak at Stroke
Association patient education sessions.
New Initiatives
We are currently exploring ideas to develop further links
and improve communication with GPs and practice
nurses in order to further improve stroke risk factor
management.
Review of Clinical Effectiveness
indicators:
Clinical Effectiveness Indicator 1: Skills Mix
Description of Issue and Rationale for
Prioritising
The safer staffing forum has been tasked with ensuring
the standards in the National Quality Board document
are adhered to in relation to reporting safer staffing
levels. The forum has established a reporting system
that records shifts on a daily basis against an agreed
actual versus planned level and RAG rates such shifts
accordingly.
The shifts are collated monthly and submitted via Unify
as required by the NQB standards and published
nationally.
The safer staffing tools for in patient mental health
services have yet to be released from NICE and as
such the forum is prioritising the reporting system
and addressing any areas of concern by undertaking
assurance visits and action planning any areas
required.
Aim/goal
The goal of the safer staffing forum is to ensure
ongoing compliance with the NQB standards and to be
42 Annual Report and Accounts
prepared for the launch of the inpatient mental health
guidelines released by NICE in Oct 2015.
Clinical Effectiveness Indicator 2: Admission
avoidance in A&E
Current Status
Description of Issue and Rationale for
Prioritising
All inpatient ward areas (as shown previously in this
report in the skill mix table in part two) have undertaken
a data collection exercise against recognised evidence
based and appropriate safer staffing tool. The
outcomes of this first data collection are informing
future data collection processes and plans to inform
commissioners of the potential financial impact
the safer staffing tools may have on the effective
management of the inpatient facilities. This work is
at the very early stages and cannot be absolutely
relied upon until the actual tools are published but it is
hoped that undertaking such an approach will ensure
readiness and preparedness for the future.
We have reported staffing levels on our wards for all
inpatient areas meeting 100 per cent compliance. As
detailed in part two we are also submitting data for
planned staffing versus actual staffing and where there
are any outliers, we have now introduced safer staffing
clinical visits.
Identified Areas for Improvement
The safer staffing forum are now engaging with the
organisational learning and development department
in order to examine the implications of the safer staffing
models and skill mix. This will also inform training
and development programmes to ensure delivery on
the required workforce denoted by the safer staffing
review.
Current Initiatives
The safer staffing forum is currently undertaking a
second dependency data collection exercise and is
working with national leads on workforce models and
informing training plans accordingly.
New Initiatives
This work is ongoing and the new initiatives regarding
skill mix and not just numbers is the next natural
progression in this longitudinal project.
The Oldham A&E therapy team is based in the A&E
department at the Royal Oldham Hospital. The service
is delivered seven days a week 8am – 8pm. The
team supports the care closer to home agenda by
completing a multi-disciplinary assessment of the
patient in the A&E department. The locality of the team,
provides a very responsive service which supports the
achievement of the four hour waiting target.
The A&E therapy team aims to support the following:
• Prevention of unnecessary admission to secondary
care of patients presenting with complex functional
and social needs
• Facilitation of safe and efficient discharges from the
A&E observation ward
• Coordination of a multi-agency approach to patient
care – the team works directly with many key
stakeholders including other community services
teams, social care and third party providers such
as Age UK and The British Red Cross
• Encouraging self-management of long term
conditions and promoting falls prevention in the
elderly to reduce the number of frequent flyers to
A&E
Aim/goal
The aim of the service is to deliver a responsive multidisciplinary assessment of any patient presenting to
the A&E department with complex functional or social
needs, often with multiple co-morbidities, to prevent
an unnecessary admission to secondary care. All
current evidence demonstrates that an admission to
secondary care is a highly inappropriate environment
to manage this type of patient due to many factors:
• Deconditioning of the individual
• High risk of infection
• Increased confusion due to disorientation
Annual Report and Accounts
43
44 Annual Report and Accounts
Current Status
New Initiatives
The service has been established in A&E since 2012
and was delivered Monday to Friday, 8am – 4pm.
The service was extended following a successful
application to the Hospital in Community (HinC)
scheme in April 2013 to be delivered seven days
a week 8am – 8pm. 46 per cent (442) of referrals
received are made during the extended time period.
The team is effective in preventing admissions; the
deflection rate in April 2014 was 93 per cent (903),
dropping to 76.6 per cent (787) in March 2015. The
main reason for the reduction in the deflection rate
is an increase in the number of patients requiring
admission for further social worker assessment.
If the application to the Better Care Fund is successful,
a positive future would include the following:
The estimated cost to Oldham CCG for admissions
avoided in 2014 was £1,040,888. Evaluation from a
patient’s perspective provided 100 per cent positive
feedback, with 81 per cent (49) stating they were
extremely likely to recommend the service to friends
and family.
• Cross-boundary working between all CCGs and
local authorities in the North East sector
Identified Areas for Improvement
Changes to the delivery of health and social care in
Oldham have had an impact on the successful delivery
of this service. The deflection rate for the team has
dropped by almost 20 per cent – this equates to over
150 admissions a year. More patients have had to
be admitted to allow for increasingly complex social
assessments and discharge plans to be agreed and
commissioned.
The service also needs a long term sustainable delivery
plan to reduce the staff turnover rate in the team and
to allow for the development of existing staff into
extended clinical roles.
Current Initiatives
Work is underway to develop an admissions pathway
for the management of the frail elderly patient, and the
A&E therapy team will be redesigned alongside this
process. An application to the Better Care Fund is also
being made which would allow the development of an
integrated health and social care model.
• The development of a frail elderly unit where all the
relevant staff were based to complete a responsive
multi-disciplinary/multi-agency assessment to
manage this complex patient group
• The development of a multi-disciplinary integrated
health and social care discharge team
• Self-management of long term conditions
• Engagement with local third party providers to
support the delivery of this model
• The development of staff to ensure the right skill
mix is available to deliver this model of working
• Access to emergency commissioned care for the
first 72 hours of the patients discharge
• Robust and responsive community teams to follow
up on discharge and work proactively to prevent
re-admission
Clinical Effectiveness Indicator 3: Six Steps to
success programme for care homes
Description of Issue and Rationale for
Prioritising
The Six Steps to Success Programme was
developed in the North West to ‘enhance and support
organisational change and develop staff working in
care homes in end of life care’.
Six steps is described in the Route to Success: a guide
to improving end of life care in care homes (2010)
produced by the National End of Life Programme.
The Six Steps to Success Programme provides training
and support for all care home staff to provide quality
end of life care, and offers a combination of workshop
learning and ongoing workplace support.
Annual Report and Accounts
45
A care home representative is trained to be a
champion for end of life care. The programme
supports residents’ wishes and preferences for their
end of life care and reduces inappropriate hospital
admissions at the end of life. It also:
quality end of life care. In addition it is hoped that it will
give increased job satisfaction and fulfilment.
The steps are as follows:
• Step 1 – Discussions as the end of life approaches
• Builds on the good work already present in the care
home
• Step 2 – Assessment, care planning and review
• Supports the development of high quality end of life
care for all residents
• Step 4 – Delivery if high quality care in care homes
• Step 3 – Co-ordination of care
• Provides a focus on new skills, tools and
approaches to enhance skills
• Step 5 – Care in the last days of life
At the core of the Six Steps Programme is the
nomination of a care home representative(s). The
pivotal role for the representative is to facilitate
organisational change to achieve the measures set
out within the Care Quality Commission assessment
criteria (2010), the End of Life Care Strategy
(Department of Health 2008), Quality Markers
(Department of Health 2009) and the Route to Success
(National End of Life Care Programme 2010).
Current Status
The care home representative is responsible for the
dissemination and implementation of the programme
in the care home.
The programme consists of eight workshops delivered
by the facilitator who supports the care home
representative to implement the programme and build
a portfolio of evidence which demonstrate how the
care home meets the Department of Health End of Life
Quality Markers for Care Homes, to assist with CQC
registration.
In addition to the workshops, there are education
sessions on advance care planning, communication
skills and end of life care which are open to all staff.
Total commitment is required of managers and owners
to support the care home representative(s) to attend all
eight workshops and sustain the Six Steps to Success
Programme.
• Step 6 – Care after death
The training has been in place since 2012 in which
support was provided from the Education Lead from
Bury Hospice using multi-professional education and
Training funding. 18 care homes across the borough
have completed the six steps training to date. The
support from the education lead was no longer
available for the last cohort. Cohort 5 commences in
April 2015.
Edge Hill University’s evidence based practice
research centre was commissioned in 2013 to explore
the impact of the programme
Results (selection):
1. 100 percent improvement for ‘Advance Care
Planning’ and ‘Communication’
2. Improvements in staff Knowledge Skills and
Confidence (KSC) 92 per cent improvement for
Spirituality skills; 79 per cent improvement for
Advance Care Planning (ACP) knowledge.
3. Increase in residents dying in their preferred place
of death from 81.5 per cent to 83.1 per cent
4. Increase in residents dying with an Advance Care
Plan (ACP) in place from 45 per cent to 56 per cent.
Aim/goal
5. EoLC documentation in care homes improved
The overall aim of the training is to ensure that all
residents with any life limiting illness receives high
Conclusion:
A clear improvement in end of life care in care homes,
greater use of appropriate tools, e.g. ACP. KSC in
46 Annual Report and Accounts
EoLC improved markedly in care home staff ensuring
residents’ wishes and preferences at end of life were
met. More confident and better trained care home staff
are now empowered to avoid unnecessary hospital
admissions and ensure more residents are able to die
in their preferred place.
Review of Patient Experience
Indicators:
An up to date audit undertaken in February 2015 in
a six steps care home demonstrated 100 per cent
compliance reflecting the care homes confidence in
discussing advance care planning, ensuring that the
resident stays in their preferred place of care and dies
in their preferred place. This demonstrates the Six
Steps to Success programme has helped care home
staff to deliver better end of life care for their residents.
Description of Issue and Rationale for
Prioritising
Identified Areas for Improvement
Presently portfolios are revisited annually and expected
to be updated as part of ensuring that care homes are
still working to six steps for end of life care. However,
due to staff turnover in care homes there is an impact
on six steps tools delivery being sustained .To enhance
sustainability, the re-evaluation of portfolios will be
done six monthly alongside a care home visit. Any
issues identified can then be dealt with sooner.
A training need for symptom management has been
identified therefore more in-depth education around
symptom management will be added to the training
programme.
Current Initiatives
Alongside the six steps we have introduced an oral
care champion’s course delivered by oral care experts.
The aim is to improve oral care especially
at end of life when a patient can no longer take fluids.
The programme is a pilot study in Bury and is still
in process. It is hoped it will be completed by end
of 2015.
Patient Experience Indicator 1:
Self Management
As a Trust our vision is ‘to deliver the best possible
care to patients, people and families in our local
communities by working effectively with local partners,
to help people to live well’. This quality priority outlines
our approach to supporting this vision through
developing self-management options. There are a
number of important considerations in the planning
and delivery of care with our patients that reinforce the
importance of developing a self-management ethos,
these include:
• Around 15 million people in England have one or
more long-term conditions. The number of people
with multiple long-term conditions is predicted to
rise by a third over the next ten years
• People with long-term conditions are the most
frequent users of health care services, accounting
for 50 per cent of all GP appointment and 70 per
cent of all inpatient bed days
• Treatment and care of those with long-term
conditions accounts for 70 per cent of the primary
and acute care budget in England
• Around 70-80 per cent of people with long-term
conditions can be supported to manage their own
condition (source: Department of Health)
New Initiatives
Self-management has been identified as a key
organisational priority and enabler which contributes
to achievement of the ambitions set out in the Trust
Service Development Strategy.
We will be considering developing the approach
specifically around care homes with residents who
have learning disabilities.
A report was submitted to the Service Transformation
Group in April 2014, namely “Self-management using
an Organisational Development (OD) Approach” that:
Annual Report and Accounts
47
• Defined what is meant by self-management
• Summarised the outcomes from mapping of selfmanagement activity and highlighting themes
• Reviewed progress on the pilot underway within the
Oldham cluster;
• Provided feedback from the recent Service User
and Carer conference where self-management was
the main focus
• Proposed a framework for the coordination and
development of a programme to support the
Divisional Business Units with the delivery of this
agenda
• The Service Transformation Group maintains an
overview of this agenda
• The My Health My Community web site was
procured and is now in development
• A number of animations and videos have
been developed to support self-care and
self-management
• The first prospectus for face-to-face delivery
was launched
• First face-to-face delivery in Bury and the Rochdale
borough have taken place and have been well
evaluated
Aims/Goal
• Third sector organisations have booked courses
The overarching aims and goals are to develop a selfmanagement support culture by addressing three key
areas, as identified by the Health Foundation as being
crucial to support the shift from paternalism to enabling
and self-management. These areas are:
• Sugar3 app was launched at the end of March. This
app supports children and young people living with
Type 1 diabetes to become more knowledgeable
and take more control of their condition, delivering
training suitable to their age/stage of development
as well as providing an interface to their diabetes
clinician to enable targeted intervention that meets
their individual needs
• Supporting staff to work in partnership with
patients, engaging with principles of co-production
and ensuring the patient and clinician are equal
experts in the relationship
• Supporting patients to become more empowered
and activated, enabling them to feel confident
and competent to take increased control of their
own health, care and wellbeing, and to increase
motivation where there is ambivalence
• Ensuring there are systems in place to support
both the above, for example education resources
both on-line and face-to-face, the development of
new apps etc, all harnessed through My Health My
Community
Current Status
• An over arching Living Well Strategy Group was
established to deliver shared leadership between
the development/delivery of My Health My
Community and the self-management toolkit
• Overarching outcome measures and anticipated
areas of impact were identified as part of the Living
Well project initiation document which is being
monitored and tracked through the Strategy Group
48 Annual Report and Accounts
• Development of an asthma app commenced,
which will be modelled on the Sugar3 app but
will support education and self-management for
children and young people with asthma
• Community Services Bury has embarked on a
cross-borough initiative to enable teams to selfassess their service delivery model against best
practice in self-management support and develop
action plans for improvement
• Heywood, Rochdale and Middleton now has a
number of self-management support champions,
enabling local leadership and adoption at scale
of the principles underpinning self-management
support
• Flo Simple Telehealth (a text-based solution to
support self-management) was implemented in the
Healthy Minds service support people attending
groups to manage stress and anxiety, helping them
to engage with their care plans more effectively,
delivering a reduction of 25 per cent in nonattendance, and a 22 per cent increase in clinical
outcomes for the cohort of patients using Flo in
addition to course attendance. Further pathways
were developed for example using Flo to support
patients, where appropriate, to be able to selfmanage their own wound care
• The development of a patient experience strategy
began, with a named organisational executive
sponsor and operational lead
• Three engagement events were held with staff
and patients/carers (approximately 250 people
attended in total), the outcomes of which will form
the basis of the patient experience strategy
Improvements in services adopting a self-management
culture are being tracked through a combination of
measures and will be monitored through the Living Well
Strategy Group.
Impact and outcomes of out the My Health My
Community products are being monitored in a range of
ways, for example courses are evaluated, participants
are requested to complete a pre and post-module
knowledge questionnaire, and attendance is tracked.
All online content will have built in analytics enabling
tracking of utilisation and quality.
Wider outcomes will be tracked through online
questionnaires and performance data. All these
measures will be tracked through the Living Well
Strategy Group.
The patient experience partnership forum is
responsible to oversee the on-going review of the
patient experience strategy, regular updates will also
be provided to the Trust’s Quality Group and where
appropriate the Trust Board.
Identified Areas for Improvement
Offering teams the toolkit and delivering workshops
and awareness-raising had some impact; however
it was felt that further activities were needed to drive
a more robust culture of self-management support
throughout the organisation. Plans are in place for
further development throughout 2015-16.
in the process of advertising and encouraging
attendance. The use of volunteers was very successful
in increasing awareness of the project in the Heywood
area and this will be developed further in other areas.
Maintaining a continual dialogue with service users,
patient experience partnership forum, staff and the
wider audience will be crucial to ensure all areas are
continually updated on the progress and development
of the patient experience strategy and where
appropriate are able to challenge varying elements of
the strategy.
Current Initiatives
Self-Management Toolkit
In order to support an increased self-awareness of
competency within teams, baseline measurement
will be supported, in order to recognise areas of
strength and areas for development, begin to set
benchmarks, and ensure the patient’s experience of
self-management support is captured and acted upon.
To that end the Bury work will inform next steps across
the organisation in relation to baseline assessment.
It is further recognised that the principles contained
within the Self-Management Toolkit would usefully
feature within the My Health My Community offer and
this will be explored further during the early part of
2015.
With respect to implementing the Toolkit, Service
Directors will continue to receive support from OL&D to
increase their awareness and skills in implementing the
contents of the Toolkit to support their delivery models.
New Initiatives
• As part of My Health My Community, an asthma
app is being developed for children aged 6 to 15
who have asthma. The app is being developed
from the same model as the Sugar3 diabetes app.
The app is intrinsically linked to the care pathway
for these children. It will enable them to track their
own learning, send updates to their nurses, email
their nurse, book Skype consultations and track
their own condition.
While the launch of the face-to-face courses was
successful, potential for improvement was identified
Annual Report and Accounts
49
Patient Experience Indicator 2: Life Stories
Description of Issue and Rationale
for Prioritising
Life story work is being used increasingly in our service
with people at all stages of dementia; there are multiple
benefits but crucially to communication. Speech and
Language Therapists aim to facilitate people with
dementia and communication needs to develop their
own life story work as much as possible within therapy.
Life story work is a way of capturing information a
person chooses about their life and all the things they
like to communicate about, this can be any format from
a personal profile within care plans to a box of objects,
music playlists, DVDs or a book. We identify the best
format for the individual and the feedback has been
tremendous. It is an invaluable tool, not only for aiding
word finding difficulties and memory but an anchor
to develop conversation strategies and highlight
communication strengths and skills at any stage of
dementia. Most important of all it is a way of helping to
maintain a person’s identity and support old and new
relationships with carers.
Speech and Language Therapists identify the format
and design of life story work to ensure it can assist
communication in the best possible way. Our feedback
tells us the life story work has been essential when
there have been transitions in care such as hospital
admissions, care packages commissioned and moves
into care. We receive a stream of feedback from staff
(e.g. within the RAID teams) how much the life story
has helped the person they have been working with in
the hospital/care on admission and how life story work
makes interactions, engagement, person-centred care
and care planning much more achievable.
Our service is aware that there is little existing training
in life story work outside our service. Many care staff
are interested but unsure how life story work fits within
their role and also families and friends of people with
dementia are keen to try and offer support via life story
work but do not have the information or know where to
start.
Speech and Language Therapy students currently
attend The Meadows in Stockport for their first year
‘taster’ placement and work with clients on wards or in
50 Annual Report and Accounts
the community to support them in developing
life story work.
EDUCATE are a Stockport organisation of people with
dementia raising awareness about the condition. They
educate others about their experiences of living with
dementia and do numerous training sessions and
talks up and down the country. Giving EDUCATErs the
opportunity to take part in the Speech and Language
Therapy student placement has led to combining the
student project so students help members develop
their own life story book whilst learning from EDUCATE
members about dementia.
Aim/goal
The next step of this successful venture; bringing
together the students with the EDUCATErs has enabled
EDUCATErs to experience the benefits of life story work
first hand and then share this with others with-in their
training roles.
The goal from here was to develop specific life story
training that EDUCATE deliver alongside Speech and
Language Therapy and this has been achieved jointly
via Stockport dementia Care Training.
Current Status
Speech and Language Therapy students have been
working closely together with EDUCATE members to
facilitate their life story work, which has been a positive
person centred way to begin their training and learning
in dementia. The students always tell us how much
they get out of the placements, learning from people
with dementia about their experiences.
The EDUCATErs that have been involved with the
student project and now educate others about how
life story work helps their communication and living
with dementia. Speech and Language Therapy have
developed training sessions run jointly with EDUCATE
and Stockport Dementia Care Training. This has been
delivered to various staff within the care sector: NHS
staff, care home staff, agency staff and volunteers. A
carers (family members/friends) session was also held,
which was very well attended.
The training has been very well received and the
EDUCATE members have inspired many of those
who have attended to start and develop life story work
but at the same time develop strategies in assisting
communication. The feedback forms from the sessions
contain lots of positive comments and further verbal
and written thanks/good feedback has been sent
to Speech and Language Therapy and Stockport
Dementia Care Training.
Current Initiatives
Feedback from those we have worked with dated
5th February 2015:
New Initiatives
We ‘were so thrilled with this ‘life story’ book’
‘They must have spent a very long time to produce this
wonderful book. It was so professional, and will give so
much pleasure, not only to (us) but to our children and
grandchildren’
Feedback from those we have worked with dated
5th April 2013:
‘We can both share the memories together in a very
simple way that is clear and helpful especially when my
husband forgets who I am’
‘Thank you all so much for your help and compassion’
Identified Areas for Improvement
The life story sessions have been well attended
and received good feedback however the skill and
experience of staff varies so now the training is to
be divided into ‘an introduction for beginners’ and
‘workshop for more experienced staff’.
Currently the life story student project runs once a year
with up to four students supporting 2-4 people with
Dementia. The Life story training runs 2-3 times a year
however EDUCATERs do bring their life story work into
other training/projects that they take part in.
The attendance at the courses indicates the demand
for more life story work support and training is there but
we have limited time and resources. There is also lack
of support for those in the community who are unable
to make the training and also those who need more
hands on support than training.
Currently the next workshop for Life story training
with Stockport Dementia Care Training, Speech and
Language Therapy and EDUCATE is planned for
March.
In January 2015 a Life Story Event was held with
the Memory Assessment Service for people with
dementia and their families/carers known to this
service. EDUCATE, carers, the therapy team and the
Alzheimer’s society were also involved. People enjoyed
the opportunity to see lots of resources, examples
and meet people with dementia, experienced carers,
staff and others also wanting to make a start on life
story work. Again the feedback was very positive and
promising that people talked about how enthused they
were and knew what direction to go in following this
event. The hope is to repeat this event in future.
Patient Experience Indicator 3:
BUILD Aftercare
Description of Issue and Rationale for
Prioritising
Over the years national substance misuse treatment
strategies have emphasised the need to retain
people in treatment, with specific emphasis on harm
reduction. Current strategy emphasises successful
exits from structured treatment, with a more holistic
approach to sustained abstinence and recovery. Key
performance indicators previously concentrated on
retention in treatment. Services are now measured
against non-representation to treatment. Services had
to change accordingly and BUILD is our response to
the challenge.
Through consultation with our service users it became
clear that they left treatment with confidence for their
long term recovery, but after a short period they began
to struggle and did not know where to turn for support.
As a response, the Drug and Alcohol Directorate
worked with service users to develop the BUILD after
care offer.
Annual Report and Accounts
51
Aim/goal
The aim and goals of BUILD were set by service users
and reflect their needs and aspirations. It has been
operational for over two years. For those who entered
treatment with a stated goal of long term abstinence
BUILD is an available option. The BUILD pathway is
straightforward:
• When an exit care plan is agreed (e.g. a planned
medication reduction, in patient/community detox)
the key worker will introduce the service user to a
pathway worker and volunteer
• The pathway worker and volunteer work with the
person to put together a post detox and long term
recovery action plan, based on creative use of time,
linking in with wider support networks
• The pathway worker and volunteer keep contact
with the person throughout the detoxification
programme for welfare support
• When the programme is complete the pathway
worker makes weekly contact by telephone with
the person for welfare checks. The person can also
access the twice weekly drop in meetings
• Flexible BUILD support has been developed to
remain alongside the person in their recovery for as
long as required. However, if successful, in time the
need for BUILD should diminish
Current Status
BUILD has a “step-up, step-down” approach. If a
person relapses whilst accessing BUILD this can be
addressed without the need to re-enter structured
treatment. However, if this deteriorates to relapse, a
quick return to structured treatment is guaranteed. This
guarantee takes some of the fear out of attempting
abstinence, especially for those who have tried in the
past (pre-BUILD) and been unsuccessful.
Drop-in peer support groups and follow up welfare
phone calls from volunteers and pathway workers
are delivered on different days in different boroughs,
for example in Stockport these take place on a
Monday and a Thursday. There is a BUILD diary which
volunteers use to rota themselves into sessions.
52 Annual Report and Accounts
BUILD is currently operational in three boroughs,
Oldham, Tameside and Stockport. Stockport BUILD
was the first to be developed, with a pathway worker in
place two years ago. Oldham has been operational for
12 months and Tameside for six months. In Oldham an
average of six people per month have been referred to
BUILD since Jan 2014.
In Tameside an average of four people per month
have been referred to BUILD since its inception in
September 2014.
Performance figures are more readily available for
Stockport • 114 service users have received follow up welfare
telephone contact
• Drop-in peer support groups on a Monday and
Thursday in Stockport have grown steadily in
attendance to between 10 and 20 people per group
• 231 people have remained out of structured
treatment for 12 months or more
• 44 people have been supported to engage with
Alcoholics Anonymous and Narcotics Anonymous
Identified Areas for Improvement
The offer considers the person not the substance
and is available to all service users who achieve
abstinence. However, it has had a higher up take
amongst alcohol service users than other substances,
particularly opiate users. Traditional forms of alcohol
treatment have included group work programmes,
whereas opiate treatment has had a strong 1:1
bias, particularly in the management of substitute
prescribing. As services reconfigure and evidence
based group work interventions play a greater role in
treatment for illicit drug users, it is expected BUILD
uptake will become more balanced.
Current Initiatives
The BUILD offer is facilitated and supported by
pathway workers and trained volunteers, all of whom
are ex-service users or have been affected personally
by substance misuse. Many of the pathway workers
and volunteers are active in the mutual aid fellowships
and enable personal introductions to the fellowships
for those who would benefit. This is crucial for people
attempting abstinence for the first time in many years,
and whose confidence and self-esteem may be low. At
this stage the risk of relapse is high and appropriate
support invaluable.
The fact that pathway workers and volunteers have
personal experience of treatment is valued by service
users, and is a unique aspect for an NHS provider.
Ex-service users have a fluency in the language of
recovery which only personal experience can create.
This proves effective for the credibility of BUILD, and
helps volunteers and pathway workers maintain their
own recovery. There are obvious risks which need to be
addressed. Pathway workers and volunteers need to
strike a balance between managing their own recovery,
and supporting others in theirs. Interacting with people
who are not fully abstinent can be a relapse trigger
point. Supervision and close support is provided
and is crucial in keeping volunteers safe. There is an
identifiable brand for BUILD across all boroughs within
the directorate. This helps with continuity and a smooth
transition for people moving across boroughs.
Future Initiatives
BUILD meetings and support are offered out of
existing treatment service premises so remain closely
associated with those services. Whilst BUILD indicates
a strong psychological shift for the individual away
from structured treatment, moving the offer to nonaligned premises will strengthen that belief.
The future of BUILD will depend on the identified
needs of service users. Facilitators will continue to
consult with them and BUILD will evolve accordingly.
As commissioning arrangements change, good quality
mutual aid and peer support initiatives will increase in
importance and BUILD will play a key role in supporting
service users to achieve abstinence and maintain long
term recovery.
Annual Report and Accounts
53
Performance against key national priorities and national core standards
We have chosen to measure our performance against the following metrics, in line with last year. Please note,
some indicators have been added and some have been removed from what we are required to report as part of the
compliance framework.
Monitor Compliance Framework
Key Indicators
Admissions to inpatient services had access to CRHT
(Gatekeeping)
Mental Health
2014/15 Threshold
99%
99.2%
95%
receiving follow up contact within 7
days
95.0%
97.4%
95%
having a formal review within 12
months
95.4%
95.1%
95%
1.3%
2.6%
<=7.5%
205
311
99%
196.8%
95%
(quarterly
target)
99.3%
99.3%
97%
Employment Status
98.9%
99.1%
50%
Accommodation Status
98.6%
97.0%
50%
Having HoNOS assessment in last
12 months
89.1%
79.3%
50%
Overall - combined results of above
96.0%
91.8%
50%
Achieved
Achieved
n/a
A&E: maximum waiting time of four hours from arrival to
admission/transfer/discharge
99.9%
99.8%
95%
Data Completeness:
Community Services
Community care - referral to
treatment information
57.8%
57.8%
50%
Community care - referral
information
82.8%
90.8%
50%
Community care - treatment activity
information
80.2%
76.6%
50%
Care Programme
Approach (CPA) Adults
Minimising mental health delayed transfers of care
Meeting commitment to serve new cases of psychosis by Early
Intervention Teams (Based on VSMR Target Line 5378)
Mental Health data completeness: identifiers (MH MDS)
Mental Health data
completeness:
outcomes for patients
on CPA
Certification against compliance with requirements regarding
to health care for people with learning disability
Community
2013/14
Trustwide
MRSA bacteraemias
0
0
0%
Trustwide
Clostridium Difficile toxin positives
1
2
N/A
54 Annual Report and Accounts
Other additional content relevant to
the quality of NHS Services
As Pennine Care has expanded to comprise services
across mental health and community settings, the
delivery of quality care remains at the forefront of the
organisation. The Board has reviewed the quality of
care and the results have led to numerous service
improvement initiatives detailed in this year’s Quality
Account.
The Trust continues its commitment to improving the
services we provide and positive patient experience
and provision of quality care remains central.
We have continued to ensure that as services
develop, quality is maintained and against any cost
improvement programmes, the Trust has a clear
governance and accountability framework in place to
manage these. All relevant service redesign schemes
are subject to a quality impact assessment and are
measured in terms of patient experience, patient safety
and clinical effectiveness. Schemes are assigned a
risk rating and are monitored closely through identified
corporate structures.
Updated audited figures and the 2014/15 audited
indicator of patient safety results have been included
within the ‘Department of Health mandatory quality
indicator set to be included in the 2014/15 Quality
Accounts’ table. We can confirm that all the other
changes since consultation have been yearend and
general formatting.
Annual Report and Accounts
55
Annex
Statement from Commissioners,
Local Healthwatch organisations and
Overview and Scrutiny Committee
Statement from Clinical Commissioning
Groups (CCGs)
CCG commentary on Pennine Care NHS Foundation
Trust Quality Account 2014/15 (mental health and
community services)
Quality and safety of services is of paramount
importance to the CCGs. As such we welcome the
opportunity to comment on the Quality Account
2014/15 for Pennine Care NHS Foundation Trust
(PCNFT).
In relation to progress against the priorities set for
2014/15 to improve quality, we welcome the progress
made in developing and implementing the Quality
Thermometer and recognise the importance of this
work in enabling services to see quality improvements
‘at a glance’. As commissioners we have highlighted
the need to improve data quality this year and this is a
positive move to look at further refinement to capture
quality outcomes and promote improvements across
all services. This year we undertook a quality and
safety review with PCNFT to explore in greater depth
how the organisation provides safe, effective services
with positive patient experience, and the challenges
PCNFT can face to do this. In 2015/16 we will continue
to work with PCNFT through regular in depth reviews
in selected services and quality themes, which will be
incorporated into the quality assurance processes.
We also expect PCNFT to continue its attention to
improving data quality and accuracy in 2015/16,
so as to be able to inform appropriate change and
development and to ensure oversight and escalation
of quality and safety issues both within PCNFT and to
commissioners.
PCNFT has continued its commitment to the
recommendations of the Francis Report and to embed
the six C’s (Compassion, Courage, Commitment,
Competency, Care and Communication) into practice,
56 Annual Report and Accounts
through implementing a detailed action plan applied
across the organisation. The CCGs will continue to
review this work to ensure that this commitment is
maintained in 2015/16, so that patients and service
users can be confident that they will be treated with
dignity and respect.
We recognise the extensive work undertaken to
support self-management with people living with
long term conditions, and welcome the wide ranging
innovative and inclusive approaches in developing this.
We look forward to this developing further, as it also
underpins the priority to avoid unnecessary hospital
admissions in 2015/16.
We have seen good progress in safer staffing, in
PCNFT’s approach to investigating and addressing
areas of lower staffing, and its on-going work to ensure
safe staff skill mix for optimum care for patients. Last
year we asked for the work programme on skill mix
to be extended beyond mental health services, and
we are pleased that this is being progressed into
community services.
We are pleased to see the focus on safeguarding
reflected again in the Quality Account, highlighting
PCNFT’s on-going commitment to safeguarding;
in 2015/16 we will continue to seek assurance that
safeguarding arrangements by PCNFT fully meet its
statutory responsibilities.
We recognise the work already underway to engage
patients and service users, and look forward to the new
Patient Experience Strategy this year. We are pleased
with increasing response rates for Friends and Family
Test in community services, since its introduction to
PCNFT services this year, but we also wish to see an
increase in the number of responses from patients
using mental health services. We welcome the work
to look at child friendly version and bring in the child’s
voice. In 2015/16 we will look for the outcomes of
improved systems to capture patient experience
effectively, through quality monitoring processes. We
would like to see how this information triangulates
with complaints and serious incidents to improve data
quality and inform further improvements.
Reporting of patient safety incidents is crucial for
organisational learning and the prevention of such
incidents recurring. Last year we also asked for further
focus on lessons learned across services following
incidents, which was supported by using a CQUIN
scheme in 2014/15. We recognise the progress
made so far, and we will continue to seek assurance
on the reporting, management and learning from
incidents and that processes comply with new national
guidance.
We support the identified priorities for 2015/16; in
particular suicide prevention is a key challenge where
improved outcomes will have a significant impact on
people who may be at greater risk, such as young
people, and their families. Admission avoidance also
aligns with CCG priorities to improve the experience
and appropriate care for people.
We recognise the challenge to present the breadth
of the quality improvements across the mental health
and community services, and as such consider
this Account provides a snapshot of the extensive
programme for quality improvement that has been
undertaken. To further demonstrate this we would like
to see further reflection of the outcomes we know have
been achieved in localities across the service footprint.
Overall, we support the significant quality
improvements achieved and look forward to working
with Pennine Care to further develop high quality
services for our populations in 2015/16.
The information presented in this Quality Account
reflects the performance on quality reported to the
CCGs through its contract monitoring processes;
PCNFT and the CCGs meet monthly to review its
performance in relation to quality and safety, including
monitoring progress against CQUIN schemes
and quality indicators, for both mental health and
community services. The CCGs are not responsible
for verifying data contained within the Quality Account
that is not part of these contractual or performance
monitoring processes. In 2015/16, the CCGs will be
seeking assurance on actions identified in the Account
in relation to mandatory quality indicators.
NHS Heywood, Middleton and Rochdale CCG (HMR
CCG) is the lead commissioner for Pennine Care NHS
Foundation Trust mental health services. Bury CCG
leads in seeking assurance for the quality and safety
of Pennine Care Foundation Trust community services
on behalf of NHS Heywood, Middleton and Rochdale
CCG. Our response to Pennine Care Foundation
Trust’s Quality Account 2015/16 is on behalf of the
following CCGs:
• NHS Bury CCG
• NHS Oldham CCG
• NHS Stockport CCG
• NHS Tameside and Glossop CCG
• Nine other associate CCGs
Susan Savage
Executive Nurse/Director of Quality & Safety, HMR
CCG and Chair of the joint commissioner and PCNFT
Quality Monitoring Group.
30 April 2015
Statement from local Healthwatch
Organisations
No feedback received.
Joint Health Overview and Scrutiny
Committee (JHOSC) for Pennine
Care – Response to the Quality
Account 2014/15
The Joint Health Overview and Scrutiny Committee
discussed the Trust’s Quality Account at two meetings
of the Joint Committee.
Quality Accounts are an important way for local NHS
services to report on quality and show improvements
in the services they deliver to local communities and
stakeholders, while at the same time enhancing public
accountability. The quality of the services is measured
by looking at patient safety, the effectiveness of
treatments that patients receive and patient feedback
about the care provided.
The primary aim of the Quality Account is to support
the NHS in improving the quality of healthcare services.
Members of the Joint Committee have scrutinised the
Annual Report and Accounts
57
three priorities for 2014/15 as well as additional data
provided by the Trust and the priorities identified for
2015/16.
The Joint Committee supports the declared levels of
compliance in relation to all three priority areas.
In respect of Priority one – the Quality Thermometer;
Members of the JHOSC expressed support for the
project. Members received assurances from the Trust
that the project will not be too onerous for staff in terms
of data collection and staff training will be provided.
Going forward, members asked that the quality
thermometer data be collated and shared within the
Trust.
Priority two – Self management; Members of the
JHSOC commended the different self management
schemes ongoing within the Pennine Care Foundation
Trust footprint. Members asked that the examples
of good practice be shared across the footprint.
Members of the Committee also sought assurances
that the quality of the different services provided is
continually monitored.
Priority three – Skills Mix; members welcomed the
emphasis placed by the Trust on staffing levels and
skills mix on inpatient wards within Pennine Care.
Elected members were very keen to receive information
on the visits undertaken by the Safer Staffing Clinical
teams to the ten wards identified within the report.
Members were happy with the feedback given with
regards to the visits and will continue to monitor the
work commenced in relation to the skill mix modelling.
Trust Executives have attended every meeting of
the Joint Committee during this municipal year and
continue to engage well with the Joint Health overview
and scrutiny committee.
Members of the Joint Committee are mindful of the
ongoing financial challenges faced by the Trust, and
want to ensure that the Trust’s commitment to high
quality service provision would continue to underpin
all areas of service development. We know that in this
financial year the trust will need to make decisions
which will have some bearing on the way the Trust
operates and we are keen to – wherever appropriate
58 Annual Report and Accounts
and possible – engage in this process at the earliest
possible stage.
All Members of the Joint Health Overview and
Scrutiny Committee April 2015
Statement from local Health and
Wellbeing Boards
No feedback received.
Statement of Directors’
Responsibilities
The Directors are required under the Health Act 2009
and the National Health Service (Quality Accounts)
Regulations 2010 to prepare Quality Accounts for each
financial year.
Monitor has issued guidance to NHS foundation
trust boards on the form and content of annual
Quality Reports (which incorporate the above
legal requirements) and on the arrangements that
foundation trust boards should put in place to support
the data quality for the preparation of the Quality
Report.
In preparing the Quality Report, directors are required
to take steps to satisfy themselves that:
• The content of the Quality Report meets the
requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15;
• The content of the Quality Report is not inconsistent
with internal and external sources of information
including:
-
Board minutes and papers for the period April 2014 to March 2015;
- Papers relating to Quality reported to the Board over the period April 2014 to March 2015;
-
Feedback from the Commissioners dated 30/04/2015
-
Feedback from governors dated May 2015
-
Feedback from Overview and Scrutiny Committee dated April 2015
- The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, Trustwide CHS Complaints Quality Governance Report Q4 and Trustwide MH Complaints Quality Governance Report Q4 2015;
annualreportingmanual) as well as the standards
to support data quality for the preparation of the
Quality Report (available at www.monitor.gov.uk/
annualreportingmanual).
The Directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
-
The national patient survey Pennine Care NHS Foundation Trust Mental Health Survey dated 18 September 2014
-
The national staff survey 2014
Chairman
27 May 2015
-
The Head of Internal Audit’s annual opinion over the Trust’s control environment, the Draft Internal Audit Annual Report 2014/15 dated May 2015
Michael McCourt
-
Care Quality Commission Intelligent Monitoring Reports dated October 2014, November 2014, and April 2015
John Schofield
Chief Executive
27 May 2015
• the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;
• the performance information reported in the Quality
Report is reliable and accurate;
• there are proper internal controls over the collection
and reporting of the measures of performance
included in the Quality Report, and these controls
are subject to review to confirm that they are
working effectively in practice;
• the data underpinning the measures of
performance reported in the Quality Report is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and
• the Quality Report has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts
regulations) (published at www.monitor.gov.uk/
Annual Report and Accounts
59
Independent Auditors’ report to the
Council of Governors of Pennine
Care NHS Foundation Trust on the
Annual Quality Report
Audit Code and scope of this work
We have performed this work in accordance with
Monitor’s Detailed guidance for external assurance
on quality reports 2014/15 and Monitor’s Detailed
requirements for quality reports 2014/15 which were
issued in February 2015, and the NHS Foundation
Trust Annual Reporting Manual 2014/15.
Reports and letters prepared by external auditors
and addressed to governors, directors or officers
are prepared for the sole use of the NHS Foundation
Trust, and no responsibility is taken by auditors to
any governor, director or officer in their individual
capacity, or to any third party. The matters raised in
this report are only those which have come to our
attention arising from or relevant to our work that we
believe need to be brought to your attention. They are
not a comprehensive record of all the matters arising,
and in particular we cannot be held responsible
for reporting all risks in your business or all internal
control weaknesses. This report has been prepared
solely for your use in accordance with the terms of our
engagement letter dated 25 March 2015 and for no
other purpose and should not be quoted in whole or in
part without our prior written consent. No responsibility
to any third party is accepted as the report has not
been prepared for, and is not intended for, any other
purpose.
Background and scope
NHS foundation trusts are required to prepare and
publish a Quality Report each year. The Quality Report
has to be prepared in accordance with the NHS
foundation trust Annual Reporting Manual (“the FT
ARM”).
As your auditors, we are required to undertake work on
your Quality Report under Monitor’s Audit Code and
Monitor’s ‘Detailed Guidance for External Assurance on
60 Annual Report and Accounts
the Quality Reports 2014/15’ (‘the detailed guidance’)
which was published in February 2015.
The purpose of this report is to provide the Council
of Governors of Pennine Care NHS Foundation Trust
(“the Trust”) with our findings and recommendations
for improvements, in accordance with Monitor’s
requirements. It is referred to by Monitor as the
“Governors report”.
Scope of our work
We are required by Monitor to review the content of
the 2014/15 Quality Report, test three performance
indicators and produce two reports:
• Limited assurance report: This report is a formal,
public document that requires us to conclude
whether anything has come to our attention that
would lead us to believe that:
– The Quality Report does not incorporate the matters required to be reported on as specified in annex 2 to Chapter 7 of the FT ARM and Monitor’s ‘Detailed requirements for quality reports 2014/15’(“the requirements”);
– The Quality Report is consistent in all material aspects with source documents specified by Monitor; and
–
The specified indicators have not been prepared in all material respects in accordance with the criteria and the six dimensions of data quality set out in the detailed guidance.
A limited assurance engagement is less in scope than a reasonable assurance engagement (such as the external audit of accounts). The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited compared to a reasonable assurance engagement.
• Governors report: A private report on the outcome
of our work that is made available to the Trust’s
Governors and to Monitor.
Our limited assurance report is restricted, as required
by Monitor, to the content of the Quality Report and
two performance indicators only. The Governors report
covers all of our work and, therefore, the third local
indicator which is chosen by the Governors.
Content of the Quality Report
Admissions to inpatient
services had access to
crisis resolution home
treatment teams
We are required to issue a limited assurance report
in relation to the content of your Quality Report. This
involves:
• Reviewing the content of the Quality Report against
the requirements of Monitor’s published guidance,
as specified in Annex 2 to Chapter 7 of the FT ARM
and the requirements; and
• Reviewing the content of the Quality Report for
consistency with the source documents specified
by Monitor in the detailed guidance.
Performance indicators
We are required to issue a limited assurance report in
respect of two out of the three indicators specified by
Monitor.
The indicators for the year ended 31 March 2015
subject to limited assurance (the “specified
indicators”); marked with the A symbol in the Quality
Report, consist of the following national priority
indicators as mandated by Monitor:
Specified Indicators
Specified indicators
criteria
100 % enhanced CPA
patients receiving followup contact within seven
days of discharge from
hospital
In line with the definition
included within Monitor’s
‘Detailed Guidance for
External Assurance
on the Quality Reports
2014/15’ unless
otherwise stated within
this report
In line with the definition
included within Monitor’s
‘Detailed Guidance for
External Assurance
on the Quality Reports
2014/15’ unless
otherwise stated within
this report
Our procedures included:
• obtaining an understanding of the design and
operation of the controls in place in relation to the
collation and reporting of the specified indicators,
including controls over third party information
(if applicable) and performing walkthroughs to
confirm our understanding;
• based on our understanding, assessing the
risks that the performance against the specified
indicators may be materially misstated and
determining the nature, timing and extent of further
procedures;
• making enquiries of relevant management,
personnel and, where relevant, third parties;
• considering significant judgments made by the
Trust in preparation of the specified indicators; and
• performing limited testing, on a selective basis of
evidence supporting the reported performance
indicators, and assessing the related disclosure.
Local indicator
We are also required to undertake substantive sample
testing of one further local indicator. This indicator is
not included in our limited assurance report. Instead,
we are required to provide a detailed report on our
findings and recommendations for improvements in
this, our Governors report. The Trust’s Governors select
the indicator to be subject to our substantive sample
testing. The indicator selected is:
• Patient safety incidents resulting in severe harm or
death.
Annual Report and Accounts
61
Summary of findings
No issues have come to our attention that lead us to
believe that the Quality Report has not been prepared
in accordance with the FT ARM and the requirements.
No issues have come to our attention that lead us to
believe that the Quality Report is not consistent with the
other information sources defined by Monitor.
Performance indicator
Findings
not included within our
limited assurance report
Patient safety incidents
resulting in severe harm or
death
No errors identified in
sample tested
No control issues
identified
For further information refer to page 166.
Limited Assurance Report
As a result of our work, we are able to provide an
unqualified limited assurance report in respect of the
content of the Quality Report.
Annual Governance Statement
We identified no issues relevant to the Quality Report.
For further details, see page 167.
Performance indicators
Our findings relating to the performance indicators are
summarised as follows:
Performance indicators
included in our limited
assurance report
Findings
100 % enhanced CPA
patients receiving follow-up
contact within seven days of
discharge from hospital
Five errors identified;
none impact on our
limited assurance
opinion
Admissions to inpatient
services had access to crisis
resolution home treatment
teams
One issue identified;
this does not impact on
our limited assurance
opinion
For further information refer to page 162 - 165.
Limited Assurance Report
As a result of our work, we are able to provide an
unqualified limited assurance report in respect of the
mandated performance indicators.
Detailed findings
Review against the content requirements
We reviewed the content of the Quality Report against
the content requirements which are specified in Annex
2 to Chapter 7 of the FT ARM and the requirements.
No issues came to our attention that led us to believe
that the Quality Report has not been prepared in line
with the FT ARM or the requirements.
We make recommendations for the consideration of
the Trust in relation to these matters in Appendix A.
Review consistency against specified source
documents
We reviewed the content of the 2014/15 Quality
Report for consistency against the following source
documents specified by Monitor:
• Board minutes for the period April 2014 to the
date of signing the limited assurance report (the
period). Minutes dated: 30/04/2014; 28/05/2014;
25/06/2014; 30/07/2014; 27/08/2014; 24/09/2014;
29/10/2014; 26/11/2014; 23/12/2014; 28/01/2015;
25/02/2015 and 25/03/2015;
• Papers relating to Quality reported to the Board
over the period April 2014 to March 2015;
62 Annual Report and Accounts
• Feedback from the Commissioners - Heywood,
Middleton and Rochdale Clinical Commissioning
Group, dated 30/04/2015;
• Feedback from Governors dated 11 May 2015;
• The Trust’s complaints report published under
regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, Trustwide
CHS Complaints Quality Governance Report Q4
and Trustwide MH Complaints Quality Governance
Report Q4 2015;
• The latest national patient survey, Pennine Care
NHS Foundation Trust Mental Health Survey dated
18 September 2014;
• The NHS Staff Survey 2014;
• Care Quality Commission Intelligent Monitoring
Reports dated October 2014, November 2014, and
April 2015; and
Performance indicators on which we are
required to issue a limited assurance
conclusion
As required by Monitor we have undertaken sample
testing of two performance indicators on which we
issued our limited assurance report:
1. 100 per cent enhanced CPA patients receiving
follow-up contact within seven days of discharge
from hospital
2. Admissions to inpatient services had access to
crisis resolution home treatment teams
We are required to evaluate the key processes and
controls for managing and reporting the indicators and
sample test the data used to calculate the indicator
back to supporting documentation. Our work is
performed in accordance with the detailed guidance
and included:
• The Head of Internal Audit’s annual opinion over
the Trust’s control environment, the Draft Internal
Audit Annual Report 2014/15 dated May 2015.
• Identification of the criteria used by the Trust for
measuring the indicator;
No issues came to our attention that led us to believe
that the Quality Report is not consistent with the
information sources detailed above.
• Confirmation that the Trust had presented the
criteria identified above in the Quality report
in sufficient detail that the criteria are readily
understandable to users of the Quality Report;
• Updating our understanding of the key processes
and controls for managing and reporting the
indicator through making enquiries of Trust staff
and through performing a walkthrough;
• Reconciling the reported performance in the Quality
Report to the data used to calculate the indicator
from the Trust’s underlying systems;
• Testing a sample of relevant data used to calculate
the indicator back to supporting documentation;
and
• Considering the completeness of the data reported
and performing sample testing on this where
relevant.
We only tested a sample of data, as stated above,
to supporting documentation. Therefore, the errors
reported below are limited to this sample.
Annual Report and Accounts
63
We have also not tested the underlying systems, for example the patient administration system and the data
extraction and recording systems.
Our findings are set out below. Recommendations arising from these findings are presented in Appendix B.
100% enhanced CPA patients receiving follow-up contact within seven days of discharge
from hospital
Reported performance:
2014/15 Threshold: 95%
2014/15 Actual: 97.4%
Criteria identified:
We confirmed the Trust uses the following criteria for measuring the indicator for inclusion in the Quality Report:
• The indicator is expressed as the proportion of those patients on Care Programme Approach (CPA)
discharged from inpatient care who are followed up within seven days.
• ‘Patients discharged’ includes patients discharged to their place of residence, care home, residential
accommodation, or to non-psychiatric care, or to prison.
• The indicator excludes patients who die within seven days of discharge.
• The indicator excludes patients removed from the country as a result of legal precedence within seven days
of discharge.
• The indicator excludes patients transferred to NHS psychiatric inpatient ward when discharged from
inpatient care.
• The indicator excludes CAMHS (children and adolescent mental health services), i.e. patients aged under
18.
• Those that are recorded as followed up receive face to face contact or a telephone conversation (not text or
phone messages).
• The seven day period should be measured in days not hours and should start on the day after discharge.
Issues identified through work performed:
No. Issue
Impact on limited assurance report
Sample 1
A sample of 30 CPA patient discharges were selected
for testing to ensure their inclusion in the indicator
was valid.
No impact on our limited assurance report.
Following agreement to supporting paper records
two errors were noted relating to patients recorded on
the system as CPA when supporting paper records
detailed the patients were non-CPA. One of these
patients had been followed up within 7 days and one
had not, and was therefore a breach.
64 Annual Report and Accounts
As two errors in 30 exceed the tolerable misstatement
threshold set sampling was extended and a further
sample of 30 was selected for testing.
Prior to our selection of our second sample the Trust
reviewed all CPA 7 day follow up breaches and from
this review identified one further non-CPA patient
recorded on the system as CPA.
Sample 2
Within our second sample two further non-CPA
patients were identified, both had been followed up
within 7 days.
The indicator has been restated to reflect the errors
noted. Significant work has been undertaken to justify
that the indicator is not misstated despite the level of
non-CPA patients included within the indicator.
Conclusion
Our substantive testing of the indicator identified four errors with a further error identified by the Trust through
their review of 7 day follow up breaches. The indicator has been restated to reflect the errors identified. This has
not impacted on our limited assurance report resulting in an unmodified report in respect of this indicator.
Annual Report and Accounts
65
Admissions to inpatient services had access to crisis resolution home treatment teams
Reported performance:
2014/15 Target: 95%
2014/15 Actual: 99.2%
Criteria identified:
We confirmed the Trust uses the following criteria for measuring the indicator for inclusion in the Quality Report:
• The indicator is expressed as proportion of inpatient admissions gatekept by the crisis resolution home
treatment teams in the year ended 31 March 2015;
• The indicator should be expressed as a percentage of all admissions to adult psychiatric inpatient wards;
• Patients recalled on Community Treatment Order should be excluded from the indicator;
• Patients transferred from another NHS hospital for psychiatric treatment should be excluded from the
indicator;
• Internal transfers of service users between wards in the trust for psychiatry treatment should be excluded
from the indicator;
• Patients on leave under Section 17 of the Mental Health Act should be excluded from the indicator;
• Planned admission for psychiatric care from specialist units such as eating disorder unit are excluded;
• An admission is reported as gatekept by a crisis resolution team where they have assessed*
the service user before admission;
* An assessment should be recorded if there is direct contact between a member of the team and the
referred patient,irrespective of the setting, and an assessment made. The assessment may be made via a
phone conversation or by any face-to-face contact with the patient;
• Where the admission is from out of the trust area and where the patient was seen by the local crisis team
(out of area) and only admitted to this trust because they had no available beds in the local areas, the
admission should only be recorded as gatekept if the CR team assure themselves that gatekeeping was
carried out.
Issues identified through work performed:
No. Issue
Impact on limited assurance report
A sample of 30 admissions to adult psychiatric
inpatient wards were selected for sample testing to
ensure their inclusion in the indicator was valid.
No impact on our limited assurance report.
Following agreement to supporting paper records
one error was noted where a patient was recorded
on the system as not having been gatekept, and was
therefore classified as a breach, however a hardcopy
gatekeeping form was provided detailing the patient
had been gatekept.
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The issue was isolated to gatekeeping breaches
so the Trust reviewed all breaches (a further 21
breaches). Following the Trusts review we reviewed all
breaches and found no further issues.
The error noted had no effect on the indicator outturn
and therefore restatement was not required.
Conclusion
Our substantive testing of the indicator identified one issue. No impact on our limited assurance report resulting
in an unmodified report in respect of this indicator.
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Performance indicators not included within our limited assurance report
Monitor also requires us to undertake substantive sample testing of a local indicator selected by the Governors, the
results of which are not included within our limited assurance report.
We are required to evaluate the key processes and controls for managing and reporting the indicator and sample
test the data used to calculate the indicator back to supporting documentation.
We only tested a sample, as stated above. Our reported errors below are limited to this sample.
Our findings are detailed as follows:
Patient safety incidents resulting in severe harm or death
Reported performance: 9.6%
2014/15 Actual: 9.6%
Criteria identified:
We confirmed the Trust uses the following criteria for measuring the indicator for inclusion in the Quality Report:
• The indicator is expressed as a percentage of all patient safety incidents reported/to be reported to the
National Reporting and Learning Service (NRLS) that have resulted in severe harm or death.
• A patient safety incident is defined as ‘any unintended or unexpected incident(s) that could or did lead to
harm for one of more person(s) receiving NHS funded healthcare’.
• The ‘degree of harm’ for PSIs is defined as follows: ‘severe’ – the patient has been permanently harmed as
a result of the PSI; and ‘death’ – the PSI has resulted in the death of the patient.
• The indicator is expressed as a percentage of patient safety incidents reported to the National Reporting
and Learning Service (NRLS) that have resulted in severe harm or death.
Issues identified through work performed:
No. Issue
Impact
N/A - no issues noted
No impact on our limited assurance report.
Conclusion
Our substantive testing of the indicator identified no
issues.
The recommendations associated with these findings are presented in Appendix B.
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Annual Governance Statement
In the requirements Monitor asks Foundation Trusts
to include a brief description of the key controls in
place to prepare and publish a Quality Report as part
of the Annual Governance Statement in the 2014/15
published accounts.
The Annual Governance Statement, within the
Foundation Trust’s 2014/15 Annual Report, includes the
following statement specific to the Quality Report:
Annual Quality Report
The Directors are required under the Health Act 2009
and the National Health Service Regulations 2010
to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS Foundation
Trust Boards on the form and content of annual
Quality Reports which incorporate the above legal
requirements in the NHS Foundation Trust Annual
Reporting Manual.
The Board of Directors received drafts of the Quality
Account on several occasions throughout the drafting
process.
with updates on work to improve data quality in the
past and receives regular reports on the data metrics
used in the Quality Account throughout the year.
As part of the assurance process, final drafts
of the Quality Account have been shared with
commissioners, Healthwatch and Health and Wellbeing
Boards and the Joint Health Overview and Scrutiny
panel.
As part of our report on the financial statements we
were required to:
• Review whether the Annual Governance Statement
reflects compliance with Monitor’s guidance; and
• Report if it does not meet the requirements
specified by Monitor or if the statement is
misleading or inconsistent with other information
we are aware of from our audit of the financial
statements.
The work we undertook on the Annual Governance
Statement as part of our work on the financial
statements identified no issues relevant to the Quality
Report.
The Quality Account is structured according to
detailed guidance set down by Monitor. It includes an
update on performance against priorities reported on
in 2013/14, a review of performance in 2014/15 and
targets for 2015/16.
Quality priorities were selected to reflect the wishes of
leading operational staff, clinicians, and the Council of
Governors, together with national priorities identified
by Monitor and local and regional CQUIN priorities.
Priorities cover the three domains of quality being
patient experience, patient safety and clinical quality.
The Trust is confident that the involvement of
stakeholders in the creation of the Quality Account
means that the account is an accurate reflection of
priorities.
Data used in the Quality Account has come from
reliable and robust sources subject to regular audit and
the data quality policies of the Trust. Where available,
the Trust has included external benchmarks to drive
quality improvement. The Board has been presented
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Appendices
Appendix A: Matters arising from our limited assurance review of the Foundation Trust’s 2014/15
Quality Report: Content review
Observation
Recommendation
Review of the content requirements
1.
From review of the first draft of the Quality Report
very few minor changes were required to ensure
Monitor’s required Statements of Assurance from
the Trust Board were stated verbatim.
N/A – The Trust ensure they are aware of the
requirements of the FT ARM, undertaking regular
review and incorporate this into the Quality Report.
Review of the consistency of the report with specified source documents
2.
No inconsistencies were noted however from our
review of multiple Quality Reports we noted that the
Trust’s Chief Executives statement on quality could
go into further detail in summarising performance.
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This observation was discussed with the Clinical
Lead – Service Improvement, Head of Audit and
Effectiveness and this will be considered for the
2015/16 Quality Report.
Appendix B: wMatters arising from our limited assurance review of the Foundation Trust’s 2014/15
Quality Report: Performance indicators
Observation
Recommendation
100% enhanced CPA patients receiving follow-up contact within seven days of discharge from hospital
1.
As detailed above, a number of non-CPA patients
were found to be recorded within this indicator in
error. Five errors in total were identified.
A significant amount of work was undertaken
by the Trust and PwC to justify that the indicator
is not misstated, despite the level of non-CPA
patients included within the indicator. Through this
additional justification work it was identified that the
split of CPA to non-CPA patients, on adult acute
wards, per the Trusts data is contradictory to the
knowledge and experience of senior medical staff
and the trend within mental health both locally and
nationally.
The accuracy of recording CPA follow up data must
be improved. This requires education and potentially
a change in ‘business as usual’ behaviours for
operational teams.
In addition we recommend that the Information
Team implement risk based accuracy checks on the
recording of CPA and non-CPA status.
Further investigation into the accuracy of the Trusts
performance data, especially where this contradicts
the knowledge and experience of senior medical staff,
should be undertaken.
Admissions to inpatient services had access to crisis resolution home treatment teams
2.
As detailed above one error was noted where a
patient was recorded on the system as not having
been gatekept (a breach) however a hardcopy
gatekeeping form was provided detailing the
patient had been gatekept.
The Information Team should implement risk based
accuracy checks. All breaches should be inspected to
confirm that they were indeed breaches.
Patient safety Incidences resulting in Severe Harm or Death
3.
N/A – No observations noted.
N/A
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